Tayside NHS Board. Please note any items relating to Committee business are embargoed and should not be made public until after the meeting

Transcription

1 Tayside NHS Board A meeting of Tayside NHS Board Staff Governance Committee will be held at 2:00 pm on Tuesday 14 March 2017 in the Board Room, Kings Cross. Apologies/enquiries to: Nicki Owen, , ext or nicola.owen@nhs.net Please note any items relating to Committee business are embargoed and should not be made public until after the meeting AGENDA LEAD OFFICER REPORT NUMBER 1. Chairman s Welcome and Introduction Chair 2. Apologies All 3. Minute of Previous Meeting 3.1 Minute of the Staff Governance Committee Meeting held on 13 December Committee Chair s Assurance Report - Staff Governance Committee Minute 13 December Action Points Update Staff Governance Committee 14 March Matters Arising 5. Declaration of Interests Intimation of any Updates 6. Presentations M Hussain M Hussain G Doherty G Doherty Attached Attached Attached 6.1 Spiritual Care Staff Wellbeing Services D Gordon 7. Staff Governance Standard 7.1 Staff Governance Standard All Staff are Appropriately Trained and Developed P Millar SGC/2017/09 Attached 7.2 Safe & Improved Working Environment L Wiggin/ G Doherty 8. Governance Risk If members of the Committee have questions please discuss with the Lead Officer prior to the Meeting SGC/2017/01 To Follow 8.1 Medical Workforce Strategic Risk J Mudie SGC/2017/02 Attached 8.2 Workforce Optimisation Strategic Risk J Mudie SGC/2017/03 Attached 8.3 Assurance Report on Nursing and Midwifery Workforce Risk G Costello SGC/2017/04 Attached 1

2 9. Monitoring Reports 9.1 Corporate Workforce Dashboard Staff Governance Committee and The Finance and Resources Committee J Mudie SGC/2017/05 Attached Workforce Information Report Quarter 3 J Mudie SGC/2017/06 Attached Promoting Attendance At Work Quarter J Bayne SGC/2017/07 Attached Recruitment Activity J Mudie/V Beattie 9.2 Item removed from agenda SGC/2017/08 Attached 9.3 Valuing People Valuing Staff Experience & Engagement imatter as a Vehicle to Underpin and Improvement Culture 9.4 Valuing People Development of a Whole System/Personal Development Review (PDR) & Personal Development Plan (PDP) Improvement Plan for 16/17 Update J Jones SGC/2017/10 Attached P Millar SGC/2017/11 Attached 9.5 Audit of People Management Practice C Smith SGC/2017/12 Attached 9.6 People Management Learning Directory D McFarlane SGC/2017/13 Attached 10. Annual Reports/Work Plans/Plans 10.1 Staff Governance Committee Terms of Reference Update G Doherty SGC/2017/14 Attached 10.2 Employability Services Annual Report A Smith SGC/2017/15 Attached 11. *For Noting*- If any member of the Committee has questions these can be directed to the Author and thereafter the Chair 11.1 Area Partnership Forum Assurance Update 23 November 2016 J Golden/ L McLay SGC/2017/16 Attached 12. Items for Adoption 12.1 Policy for Adoption G Doherty SGC/2017/17 Attached Research Passport Policy 13. Items for Information 13.1 Area Partnership Forum Minutes 23 November Joint Negotiating Committee Minutes 24 August 2016 M Hussain M Hussain Attached Attached 2

3 13.3 Joint Negotiating Committee Minutes 26 October Joint Negotiating Committee Minutes 14 December 2016 M Hussain M Hussain Attached Attached 13.5 Record of Attendance M Hussain Attached 13.6 Scottish Workforce & Staff Governance (SWAG) 18 January 2017 G Doherty Attached 14. Any Other Competent Business M Hussain 15. Date of Next Meeting The next meeting of the Staff Governance Committee will take place at 2pm on Tuesday 13 June 2017 in the Board Room, Ninewells. 16. In accordance with the Freedom of Information (Scotland) Act 2002 Exemption 30(b) Prejudice to Effective Conduct of Public Affairs Presentation/Report 16.1 Developing Our Culture G Doherty/ J Jones SGC/2017/18 To Follow Mr Munwar Hussain Chair Staff Governance Committee March 2017 Distribution: Members Mrs Jenny Alexander Mr George Doherty (Lead Officer) Mrs Judith Golden Mr Munwar Hussain (Chair) Mr Raymond Marshall Ms Lesley McLay Mr Hugh Robertson Mrs Alison Rogers (Vice Chair) Professor Margaret Smith Mrs Sheila Tunstall-James Non-executive Member Ex Officio Member Professor John Connell FMedSci FRSE In Attendance Dr Andrew Cowie Ms Jenni Jones Mrs Jennifer Mudie Dr Norman Pratt Miss Diane Robertson For Information Ms Gillian Collin Ms Margaret Dunning Communications Department Co. Chair. Workforce and Governance Committee Director of Human Resources, NHS Tayside Employee Director, Tayside NHS Board Non Executive Member, Tayside NHS Board Area Partnership Forum Secretary Chief Executive, NHS Tayside Non Executive Member, Tayside NHS Board Non Executive Member, Tayside NHS Board Non Executive Member, Tayside NHS Board Non Executive Member, Tayside NHS Board Vacant Post Chairman, Tayside NHS Board Area Clinical Forum Chair, NHS Tayside Associate Director Development, NHS Tayside Associate Director of Human Resources, NHS Tayside Area Clinical Forum Representative, NHS Tayside Area Clinical Forum Representative, NHS Tayside PricewaterhouseCoopers LLP Board Secretary, NHS Tayside NHS Tayside 3

4 Minute NHS Tayside Item 3.1 STAFF GOVERNANCE COMMITTEE Minute of the above meeting held at 2:00 pm on Tuesday 13 December 2016 in the Board Room, Kings Cross, Hospital. Present Ms Jenny Alexander, Co-Chair Workforce and Governance Committee, NHS Tayside Mr George Doherty, Director of Human Resources & Organisational Development, NHS Tayside Mrs Judith Golden, Employee Director, Tayside NHS Board Mr Munwar Hussain, Non Executive Member, Tayside NHS Board Mrs Alison Rogers, Non Executive Member, Tayside NHS Board Mrs Sheila Tunstall-James, Non Executive Member, Tayside NHS Board Apologies Professor John Connell, Chairman, Tayside NHS Board Dr Andrew Cowie, Area Clinical Forum Chair, NHS Tayside Ms Margaret Dunning, Board Secretary, NHS Tayside Mr Raymond Marshall, Staff Side Representative, NHS Tayside Ms Lesley McLay, Chief Executive, NHS Tayside Mr Hugh Robertson, Non Executive Member, Tayside NHS Board Professor Margaret Smith, Non Executive Member, Tayside NHS Board In Attendance Mrs Gayle Culross, Communications Manager, NHS Tayside (Item 7.3) Mrs Gaynyr Dickson, Communications Manager, NHS Tayside (item 6.1 and Item 7.3) Ms Jenni Jones, Associate Director - Development, NHS Tayside Mrs Pat Millar, Head of Knowledge and Skills, NHS Tayside (Item 9.4) Mrs Jennifer Mudie, Associate Director of HR Resourcing, NHS Tayside Mr Christopher Smith, Head of Human Resources, NHS Tayside Mr Munwar Hussain in the Chair 1. Chairman s Welcome and Introduction ACTION Mr Hussain welcomed all to the meeting especially Mrs Millar, Mrs Culross and Mrs Dickson who were presenting reports. 2. Apologies The apologies were as noted above. 3. Minute of Previous Meeting 3.1 Minute of Meeting held on 27 September 2016 The Staff Governance Committee Minute of the meeting held on 21 June 2016 was approved on the motion of Mrs Alison Rogers and seconded by Mrs Judith Golden subject to the following amendments:- Page 21 Item 9.1 Workforce Information Quarter 1 5 th Paragraph should read:- Mrs Rogers//... Item Promoting Attendance at Work 2 nd bullet point last sentence should read:- Mr Smith advised that work was being carried out to combat stress. 27

5 Minute 3.2 Committee Chair s Assurance Report Staff Governance Committee Minute 21 June 2016 Mr Hussain advised that this report had been presented and noted by Tayside NHS Board The Staff Governance Committee:- Noted the Committee Chair s Assurance Report 27 September Action Points Update NHS Tayside Item 7.4 Taking Root: Our Collaborative Leadership Commitment:- Mr Doherty and Mrs Jones advised that this area was contained within work being progressed through Developing Our Culture and an update would be provided to the March 2017 meeting. The Staff Governance Committee:- 4. Matters Arising Noted the Action Points Update. In relation to Item 3.3 of the of the Action Points Update from the meeting held September 2016 regarding Safe & Improved Working Environment it was highlighted that Mrs Wiggin had developed a short life working group to move matters forward. 5. Declaration of Interests There were no declarations of interest. 6 Presentations 6.1 STAR Awards (SGC/2016/63) Mrs Rogers gave a verbal update, she updated the Committee on the following:- The Awards were on track for rollout in January 2017 for nominations. A Short Life Working Group had been brought together and would be meeting next week. The following was highlighted by Mrs Dickson:- A request was being made to the Committee for the approval to hire an outside venue to host the 2017 NHS Tayside STAR Awards. Currently work was being undertaken in looking for sponsorship to host the event from the Venue. Costings for the use of an outside Venue were available to anyone requesting these. Audio and visual equipment was included within the pricing for an external venue. That it would be a cost benefit to the Organisation to use an outside venue rather than remain within NHS Tayside Grounds. The date being looked at was 18 May 2017 between 12 noon and 5 pm. Further funding would have to be secured as currently donations were in the region of 1,700 however it was thought that around 5,000 was 28

6 Minute required in total. Endowments support would be sought to fund the Event. If funds were not received then the STAR Awards would not go forward. The Quality Awards held previously were funded through Endowments. A request for funding could also be made to the Tayside Health Fund. The Staff Governance:- Approved requests for funding being made to Endowments and Tayside Health Fund. Approved with the use of funding to hold the Celebration Event externally to NHS Tayside due to the cost savings identified. 7. Staff Governance Standards 7.1 Involved in Decisions which Affect Them (SGC/2016/60) Mrs Golden spoke advised the Committee that Mr Alan Small who had cowritten the report was due to retire from the Organisation and wished to thank him for his dedication and support throughout the years. It was noted:- Work was underway to refresh the work of the Area Partnership Forum. The Local Partnership Forums were each at different stages of development. The development of a Local Partnership framework was at different stage of development across each of the 3 Health and Social Care partnerships. The role out of imatter for NHS staff would form a core agenda item for Local Partnership Fora. The Local Fora would provide an annual report to the Area Partnership Forum regarding local progress against the Staff Governance Standard. Partnership Walk Rounds were being carried out in Angus Health and Social Care Partnership. It was felt that this was good practice and should be brought to the attention of the other Local Partnership For a. The Staff Governance Committee:- NHS Tayside Noted the content of the report. Agreed an update would be provided to the June 2017 meeting. JG/GD 7.2 Safe & Improved Working Environment/Health & Safety Annual Report Mr Doherty highlighted that a review of Health & Safety was currently underway with a report being published in January A report would therefore be provided to the March 2017 Staff Governance Committee. LW 7.3 Well Informed (SGC/2016/62) Mrs Gayle Culross and Mrs Gaynyr Dickson were in attendance and the following was discussed:- There were concerns in relation to the responses around Senior Management visibility. Mr Doherty advised that all Health Boards across Scotland had the same issues and that nationally work was ongoing 29

7 Minute NHS Tayside around the format of the questions contained within imatter to clarify the definition Senior Management and what meaningful engagement looked like. It was agreed that an update on Senior Management Visibility would be provided to the March 2017 meeting Valuing Your NHS covered Staff Involvement and was pro-active in taking measures forward Areas that did not have PCs and use of suggestion boxes would be placed around specific areas. Spectra was moving to quarterly issues from 2017 and would provide detailed updates to Staff. The Staff Governance Committee:- Noted the Corporate Communications Department work plan for (check the dates). Noted the Facts and Figures update for Noted the Value Your NHS campaign overview. Agreed an update on Senior Management Visibility throughout the Organisation would be provided to the March 2017 meeting. MD/GD/GC 8. Governance Risks 8.1 Medical Workforce Strategic Risk (SGC/2016/64) Mrs Mudie provided an update on the following:- This strategic risk has been reworded to take into account the breadth of risks relating to the Medical Workforce. The previous version referred in the main to the anticipated changes in the training of Junior Doctors and its impact on the profile of the career grade doctors. This risk also related to the impact of the national shortage of GPs. Although GPs are in the main independent contractors, the development of the Health and Social Care Partnerships workforce plans required closer working relationships with the Primary Care and Voluntary Sectors. Discussion centred on the following:- The participation in Physician Associate training was continuing with those who have completed training being employed. A further update on this work would be provided in 2017 by the Chief Operating Officer. Dr John Davidson had been invited to the Clinical Care Governance Committee to discuss concerns in relation to Junior Doctor training numbers. The Clinical Care Governance Committee was also looking at the Junior Doctors survey and at the impact on patient safety in relation to falling numbers of Junior Doctors in training. It was also noted that these concerns would become part of the Staff Experience information. Mrs Mudie, Mr Hussain, Mr Doherty and Mrs Rogers would meet out with the Committee to discuss how to meaningfully link the different aspects of this risk that was currently being considered by the Clinical Governance Committee, the Finance and Resources Committee and the Staff Governance Committee to avoid unnecessary duplication. 30

8 Minute The Staff Governance Committee noted the following actions that were in place to mitigate the Risk:- NHS Tayside New Deal monitoring for each rota was being undertaken twice per year, with support to Lead Clinicians, managers and doctors in training in relation to the understanding, management and individual responsibilities to comply with the regulations, eg monitoring guidelines for each rota for each Trainee, pre monitoring talks to all trainees, non compliance rotas reported to Rotamaster and an identified consultant. Local Workforce Plans are developed by General Managers and Lead Clinicians to redesign models of service delivery to reduce the reliance on doctors in training. Public consultation in relation to the Shaping Surgical Services and the Review of Mental Health Services provision is being planned. The Corporate Workforce Plan and Projections will inform Scottish Government in relation to training numbers etc. Intelligence gained through participation at the North of Scotland Medical Workforce Planning Group and the opportunity to influence it. Adjustments to consultant on-call rota are made to ensure adequate senior clinician decision making is available when the more senior ST grades are unfilled. Employing Specialty Doctors and Locums, with and without training numbers, to minimise gaps in service delivery, as well as Agency Doctors. Piloting the introduction of Physicians Associates to gauge impact on rostering compliance. Engagement in social media network advertising to target the passive market. Introduction of advanced practitioner roles to support Primary Care Agreed Mrs Mudie, Mr Hussain, Mr Doherty and Mrs Rogers would meet out with the Committee to discuss Junior Doctor numbers. 8.2 Workforce Optimisation (SGC/2016/65) Mrs Mudie advised there had been a change in the risk profile in relation to the deployment of staff. She had raised the risk factor in Section 2 of the report. Section 3 of the report provided assurances that would help mitigate concerns around the issues of shift patterns at present. The Staff Governance Committee noted the following:- Directors and Chief Officers should plan for design of future service delivery taking into account Health and Social Care Partnerships, the opportunities provided by succession planning information and a national/regional Clinical Strategy and the Clinical Strategy of NHS Tayside. Local Workforce Plans to become live documents that are required to be reported upon and discussed at the Local Partnership Fora. The Local Workforce Plans to inform the Staffing Projections for NHS Tayside and the Corporate Workforce Plan. Directorate Performance and Scrutiny Groups lead by the Chief Operating Officer and the Chief Officers of the Health and Social Care Partnerships, which include operational staff management and staff governance issues. 31

9 Minute NHS Tayside The governance of the NHS Tayside Redeployment Register and procedure to be implemented in partnership with staff side. Workforce Information is to be provided to support line managers plan and manage the workforce. Finance reports identifying staffing costs to be shared in management meetings, Area Partnership Forum and NHS Tayside Board. Maintenance of an active Nurse Bank with appropriately skilled Bank Nurses. Provide regular workforce information reports to Scottish Government to inform national planning, particularly in respect of national training numbers. Implementation of an Attraction and Recruitment Strategy for NHS Tayside. Analysis of the results from the On-line Exit Questionnaire Survey along with learning from individual interviews. Management of Attendance at Work and staff wellbeing. Prospective recruitment to minimise supplementary costs as directed by appropriate budget holder or Executive Lead. Effective management of fixed term contracts. Review of shift lengths and patterns for nursing staff. 8.3 Corporate Risks Board Assurance Framework Nursing and Midwifery Workforce (SGC/2016/66) The Staff Governance Committee were pleased to see the report. Mr Doherty agreed that he would speak with the Nurse Director on the future reporting format. The Staff Governance Committee:- Noted the Corporate Risk September Noted the Corporate Risk December Monitoring Reports 9.1 Workforce Information Quarter (SGC/2016/67) Future Assurance Reporting The paper detailed the comparison of the whole-time equivalent numbers as at September 2011 and September She provided a monthly breakdown of staff for nursing, midwifery and administrative staff within the report. In the 2016/17 staffing projections a projected decrease in administrative staff had been forecast. It was noted as at the midpoint of the financial year that this forecast had not been realised. There were concerns regarding turnover in relation to Medical and Dental and AHP staff. This was influenced in part by the ageing demograph with some staff able to draw down their pensions from the age of 55. The Exit Interview process was being utilised to see why staff were leaving the Organisation. Mrs Mudie further highlighted the use of EURIS which is a European recruitment service. The EURIS portal is open at all times to encourage enquiries. To-date 32

10 Minute success in attracting candidates has been limited. The Attraction and Recruitment strategy which contains 37 actions is being implemented by Directorates and Health and Social Care Partnerships. In addition for certain medical specialities, such as Psychiatry, third party recruitment agencies who have international links have been engaged. In 2016 NHS Tayside used the Corporate Workforce Plan to meet the 5% target of staff employed between the ages of Work was ongoing in this area. There would be an aprentiship levy in future and a report would be provided on this in due course. Employability programmes continue to support individuals to be work ready or provide a stepping stone into further education. Foundation apprenticeships for school leavers was being developed for implementation in School Year 2017/18 and there was continued support for work experience for school and further education students. Mrs Golden noted that in Appendix 1B of the report, a reduction was projected. Mrs Golden queried if this was due to a vacancy factor as there were constantly challenges around nursing and midwifery staffing levels which had a higher turnover of staff. Mr Doherty referred to the national shortage of nursing and midwifery staff and advised a lot of work was being carried out in relation to the recruitment strategy. Work was being undertaken on improving and exploiting the use of social media, where a positive input about the Organisations reputation and staff experience would help to engage new staff. Junior Doctors were utilising areas such as social media to inform others of the best areas across Scotland to work. Patients also use these mediums to inform the public of their personal experiences. The Staff Governance Committee:- Noted the content of the report. Agreed the new form of reporting would provide assurance to the Committee on Workforce Strategies. Agreed a report on apprenticeship levies would be provided when guidance was available from Scottish Government and its implications assessed. 9.2 Promoting Attendance Quarter (SGC/2016/68) NHS Tayside Mr Smith advised that the attendance figures now included the NHS component of the Health and Social Care Partnerships. Work had been undertaken to communicate to managers about the Fir for Work initiative. This work had been well received. It was noted that areas of high absence included learning disabilities, Midwidery and Support Services. The committee noted some of the work being undertaken to promote attendance within the higher absence areas. It noted the role which Local Partnership Fora would have in ensuring appropriate implementation of Board policies. Mrs Golden noted concerns in relation to the percentage of staf who were absence due to stress anxiety and depression. Work was being undertaken to develop a positive culture which would promote wellbeing and, in turn, reduce absence. Mrs Tunstill-Jones asked if a national category was being developed to distinguish home and work related stress. The committee was informed that the Board had to comply with national categories which did not make the distinction. 33

11 Minute Concerns were raised as to why Return to Work interviews were not being routinely undertaken in all areas. Data of this nature should be captured. It was noted that local management may not be recording data appropriately. It was also unknown whether other policies were being utilised effectively. Mr Smith agreed to provide an update to the next meeting. NHS Tayside Mr Hussain highlighted that NHS Tayside was below the NHSScotland average in relation to promoting attendance at work rates. The Committee however required assurances that work was being carried out to mitigate issues in Midwifery and Support Services. it was agreed that action plans from Midwifery and Learning Disabilities would be brought to the next committee. Mr Smith would discuss this issue with Mrs Wiggin.. CS The Staff Governance Committee:- Noted the contents of the report. Agreed updates would be provided to the Staff Governance Committee in March Agreed discussions would be undertaken within Learning Disabilities and Midwifery and Support Services to look at improving the culture and improving staff attendance. CS 9.3. Recruitment Activity (SGC/2016/69) Mrs Mudie advised that work was being undertaken with the University of Dundee around the recruitment of newly qualified Nurses. She further highlighted there had been issues in funding of the Medical Training Fellows. During Quarter 1 and 2 it was noted that staff could be brought into the Organisation from external sources. A significant number of appointments had been made. The report highlighted a drop in Mental Health Staff along with non medical staff. There were dedicated staff working on recruitment for the Organisation under extremely trying circumstances. The Staff Governance Committee:- Noted the content of this report. 9.4 Valuing People Valuing Personal Development Plans (PDPs) Development of a Whole System/Personal Development Review (PDR) & Personal Development Plan (PDP) Improvement Plan for 2016/17 Update (SGC/2016/70) Mrs Jones advised the report provided an update of ongoing work in relation to PDPs. e-knowledge Skills Framework was the only system the Organisation had available to monitor progress. Currently IT Training was on hold due to the implementation of TrackCare. The Medical Director was working and committed to revalidation however it had been noted that e-ksf was cumbersome. The Committee noted that while Mrs Millar routinely reported the update of e-ksf throughout the Organisation, when performance review was the Chief Officers and relevant Directors. 34

12 Minute NHS Tayside E-KSF would in future be connected to imatter however the Committee was not assured this was taking place and whether staff felt valued for their work. Forth Valley had an uptake of 81% for eksf, and the Committee asked Lead Officers to link with the Board for lessons learned. Key Performance Indicators would be used within each directorate. Mrs Millar advised she was providing an update to Tayside NHS Board on eksf in 2017 with an improvement plan to increase the use of eksf. Mr Hussain agreed an update and action plan should be presented to the Board to know the risks currently involved for the Organisation. Ownership should be taken on by each Directorate and consideration had to be given to the IJB Chief Officers who would also have to report on these areas. The Staff Governance Committee:- Noted the content of the report. Agreed to review an action plan for improvement at its March 2017 Meeting. PM/Chief Officers 9.5 Valuing People Valuing Staff Experience & Engagement imatter as a Vehicle to Underpin an Improvement Culture (SGC/2016/71) Mrs Jones advised that imatter would be fully implemented across the Organisation in Staff within the Acute and Corporate Directorates had participated in at least 1 imatter cycle. IMatter would be connecting with PDPs and eksf. All staff had to be made aware of the importance of participating in imatter. Perth & Kinross were currently receiving help with implementation of imatter. The Scottish Government had confirmed that imatter will replace the National Staff Survey from A system would have to be created to ensure the Organisation was monitoring trends and acting on these. imatter data would be used by the Scottish Government for monitoring purposes and provide an early indication of issues in relation to staff engagement at a Board level. The Local Partnership Foras would provide an important part of the dialogue along with the Area Partnership Forum supporting the promotion of imatter. Data would be reported through to the Staff Governance Committee. Queries were raised as to whether Management was confident that imatter was being embedded within the Organisation and whether staff would be able to see improvements for them. Supportive actions were being put in place and staff would be able to work with imatter effectively. The Committee wished to celebrate the work carried out in relation to Support Services and the provision of paper copies of the imatter programme for those unable to utilise PCs. The process was currently in early engagement however signs were good that the process being used was working well. The Staff Governance Committee:- Noted the contents of the Report. Noted the comparison with the national reports. Noted the emerging arrangements for receiving progress reports through Local Partnership Forums. Celebrated the work achieved to date. 35

13 Minute 9.6 Non-Executive Whistleblowing Champion April to September 2016 Report (SGC/2016/72) Mrs Rogers advised the report was a 6 monthly update on issues raised through Policy and not media. Processes were being developed and more regular liaison was being undertaken with Counter Fraud Services. Staff knowledge of the Policy had increased with a Vital Signs being issued when the Whistleblowing Officer had been appointed. Promotion of the Policy was paramount and to raise staff awareness of the Policy prioirity. Further communications work would be undertaken to ensure staff were aware of the National Alert Line. The Staff Governance Committee:- NHS Tayside Noted the content of the report. Agreed discussions between Mrs Rogers and Mrs Dickson would take place to promote the Policy and National Alert Line. AR/GD 9.7. Staff Governance Terms of Reference (SGC/2016/73) An amended version of the Terms of Reference were circulated to the Committee. After discussion with Internal Audit the remit of the Staff Governance Committee was being amended to refocus the objective of the Committee and amends its emphasis to the following:- The Committee is responsible for reviewing those aspects of Best Value Work Plan which are delegated to it from Tayside NHS Board. The Committee will put in place arrangements which will provide assurances to the Chief Executive as Accountable Officer, that NHS Tayside has systems and processes in place to secure the best value for these delegated areas. The assurance to the Chief Executive should be included as an explicit statement in the Committee s Annual Report. The Committee highlighted the following:- There were to be 6 Non-Executives including the Employee Director. The Employee Director would become the Co-Chair of the Staff Governance Committee. The Staff Side Co-Chair of the Area Partnership Forum, Staff Side Secretary and the Chair of the Workforce & Governance Forum would become members of the Committee. The primary responsibility of the Committee will be to assure the Board around the structure of the workforce in the coming years. The Committee will also look at the overall staff environment and culture as it moves forward. There were concerns around Section 3.2 and the fact that the Committee could be quorate with only 3 Non-Executive members present. It was agreed that Mrs Rogers would discuss this directly with the Board Secretary and Tayside NHS Board at its next meeting. Further concerns were raised in relation to the attendance role of the Director of HR & OD. It was felt that he should be a member rather than an attendee and should have full voting rights 36

14 Minute The Staff Governance Committee:- NHS Tayside Agreed that discussion would take place between Mrs Rogers and the Board Secretary to discuss membership and quoracy of meetings. The addition of the words Clinical Care Governance Committee would be inserted into Section 5.1 after the Finance & Resources Committee. Agreed the Terms of Reference subject to the above discussion and amendment being made. AR 9.8 Occupational Health Appoints DNA Report Mr Smith highlighted the work which had been undertaken by the Occupational Health Department to minimise DNAs. The Committee noted the recommendations within the report.the Staff Governance Committee:- Noted the content of the Report Agreed an update would be provided to the September 2017 meeting CS/PL 10. Annual Reports/Work Plans/Plans There were no items for discussion. *11. *For Noting* - If Items Required Discussion Please Raise with the Chair 11.1 Area Partnership Forum Board Report 21 September 2016 (SGC/2016/75) The Staff Governance Committee:- Noted the Area Partnership Forum Board Report 21 September Staff Governance Standard Monitoring Framework (SGC/2016/76) Staff Governance Standard Action Plan Mr Courtney provided an addendum to Action 3.5 of the Staff Governance Standard Action Plan which was circulated at the meeting. The Staff Governance Committee:- Noted the Staff Governance Standard Monitoring Framework. Noted the Staff Governance Standard Action Plan Public Sector Equality Group Work Plan (SGC/2016/78) The Staff Governance Committee:- Noted the Public Sector Equality Group Work Plan Update on NHS Tayside Scheme for Medical Appraisal and Revalidation (Secondary Care) SGC/2016/79 37

15 Minute NHS Tayside The Staff Governance Committee:- Noted the Update on NHS Tayside Scheme for Medical Appraisal and Revalidation (Secondary Care) NHS Tayside Annual GP Appraisal Report 2015/16 (SGC/2016/80) The Staff Governance Committee:- Noted the NHS Tayside Annual GP Appraisal Report 2015/ Items for Adoption 12.1 HR Policies (SGC/2016/81) Skills Register Redeployment Policy Fixed Term Contract Policy Induction and Orientation Policy The Staff Governance Committee endorsed the:- Skills Register Redeployment Policy. Fixed Term Contract Policy. Induction and Orientation Policy. 13. Items for Information 13.1 Area Partnership Forum Minute 21 September 2016 The Staff Governance Committee:- Noted the Area Partnership Forum Minute 21 September Joint Negotiating Committee Minutes 24 August 2016 The Staff Governance Committee:- Noted the Joint Negotiating Committee Minutes 24 August Workforce & Governance Forum Minutes 7 September 2016 The Staff Governance Committee:- Noted the Workforce & Governance Forum Minutes 7 September Everyone Matters Implementation Plan (SGC/2016/82) The Staff Governance Committee:- Noted Everyone Matters Implementation Plan Record of Attendance The Staff Governance Committee:- 38

16 Minute Noted the Record of Attendance for information. NHS Tayside 14. Any Other Competent Business There was no other competent business 15. Date and time of the next meeting The next meeting of the Staff Governance Committee will take place on Tuesday 14 March 2017 at 2pm in the Board Room, Kings Cross. Subject to any amendments recorded in the Minute of the subsequent meeting of the committee, the foregoing Minute is a correct record of the business proceedings of the meeting of the Staff Governance Committee held on Tuesday 13 December 2016 and was approved by the Committee at its meeting held on Tuesday 14 March Chair.. Date 39

17 Please note any items relating to Staff Governance business are embargoed and should not be made public until after the meeting Item Number 3.2 COMMITTEE CHAIR S ASSURANCE REPORT STAFF GOVERNANCE COMMITTEE OPEN 13 December 2016 Performance against Work Plan STAR Awards (SGC/2016/63) Approved Staff Governance Standards Involved in Decisions which Affect Them (SGC/2016/60) Important area that indicates need for improvement, approved update with 6 monthly reporting to committee. Safe & Improved Working Environment/Health & Safety Annual Report Report to come to March 2017 meeting, postponed as review underway. Well Informed (SGC/2016/62) Continual good performance, senior mgt visibility only area slightly down on others. Update on Risks Medical Workforce Strategic Risk (SGC/2016/64) This strategic risk is at a very high level (20), monitoring of rotas, local workforce plans, public consultation (shaping surgical services/mental health), corporate workforce projections to SG, work with North of Scotland Medical Workforce Group, ensuring adequate senior clinical decision making, employment of speciality doctors, pilot physician association programme, social media and advanced practitioner roles all examples of work done, but risk is continuing at a high level. Workforce Optimisation (SGC/2016/65) This strategic risk has moved higher (20) due to the change programmes taking longer to complete. Some examples taken to ensure mitigation of risks, Local Workforce Plan reported to Local Partnership Fora, Governance of redeployment register implemented with staff side, Workforce Information to assist planning, Financial Reports shared, Maintain an active nurse bank with skilled nurses, active workforce information reports, i.e. national training numbers, Implementation of the Attraction & Recruitment Strategy for NHST, Analysis of exit interviews and individual interviews, management of attendance at work and staff wellbeing, Executive lead or budget holder authority around prospective recruitment to minimise supplementary spend, effective management of fixed term contracts and review of shift lengths and patterns for nursing staff. 1

18 Nursing & Midwifery Workforce (SGC/2016/66) Report not in correct format Munwar Hussain Staff Governance Committee Chairman January

19 Item 3.3 STAFF GOVERNANCE COMMITTEE (following 21 December 2016) DATE REF HEADING ACTION POINT LEAD STATUS 17 Feb Taking Root: Our Collaborative Leadership Commitment Update to Committee reporting on progress made L McLay/G Doherty/J Jones Update from Dec 16 meeting information contained within work being undertaken through Developing Our Culture 21 June Developing Our Culture 18 August Spiritual Care Staff Wellbeing Services 27 September 3.3 Safe & Improved Working 2016 Environment Action Follow Up Report Agenda Item March 17 An update to be provided around the David Gordon Agenda Item March 17 Service Update L Wiggin Deferred until March 17 Report being undertaken and published January September September Statutory Mandatory Training 7.3 NHS Tayside Board Members Input into Programme of welcome Events for New Employees Framework of Statutory Mandatory Training Update on Board members Involvement Agenda Item March 2017 P Millar Agenda Item March 2017 J Jones Following Developing Our Culture report from March 2017 update to be provided June December December December Well Informed 7.1 Involved in Decisions which Affect Them 9.1 Workforce Information Quarter Update on Senior Management Visibility throughout the Organisation G Dickson/G Culross/G Doherty Verbal update Update Report to be provided J Golden/G Doherty June 2017 Provide new reporting information J Mudie Agenda Item March 2017 An update on apprenticeship levies and the impact to the Organisation A report will be submitted to Sept 2017 on the impact of the levy and the Organisations ability to fund new apprenticeships Staff Governance Committee 13 December

20 DATE REF HEADING ACTION POINT LEAD STATUS 13 December December December December Promoting Attendance at Work Quarter Valuing People Valuing Personal Development Plans 9.7 Staff Governance Terms of Reference 9.8 Occupational Health Appointment DNA Report Update to be provided including improving the culture & staff attendance within Maternity and Support Services A review of the action plan for improvement C Smith Agenda Item March 2017 P Millar/Chief Officers Agenda Item March 2017 Mrs Rogers to discuss with the Board A Rogers Verbal Update Secretary quoracy and membership Update to be provided C Smith September 2017 Staff Governance Committee 13 December

21 STAFF GOVERNANCE COMMITTEE COMPLETED ACTIONS DATE REF HEADING ACTION POINT LEAD STATUS 16 February Statutory/Mandatory Training A Strategy was to be produced for Statutory/Mandatory Training P Millar/J Jones Completed Staff Governance Committee 13 December

22 Please note any items relating to Staff Governance business are embargoed and should not be made public until after the meeting `Item 7.1 SGC/207/09 Staff Governance Committee 14 March 2017 STAFF GOVERNANCE STANDARD: ALL STAFF ARE APPROPRIATELY TRAINED AND DEVELOPED 1. SITUATION AND BACKGROUND This report has been prepared to inform the Staff Governance Committee about progress during 2016 in relation to meeting the Staff Governance Standard All staff are appropriately trained and developed. There are four key elements within this standard that NHS Boards are required to ensure are in place, and each of these areas will be addressed within the report. The four elements are: All Staff Have A Regular, Effective Personal Development Plan (PDP) And Review Discussion There Is a Workforce Learning And Development Strategy In Place All Staff Have Equity Of Access To Training, Irrespective Of Working Arrangements Or Profession Resources, Including Time And Funding Is Appropriately Allocated To Meet Local Training And Development Needs 2. ASSESSMENT 2.1 ALL STAFF HAVE A REGULAR, EFFECTIVE PERSONAL DEVELOPMENT PLAN (PDP) AND REVIEW DISCUSSION One of the main strands to this Staff Governance Standard is that all staff participate in an annual Development Review and have a Personal Development Plan (PDP), for the majority of our employees; eksf is the system currently in place to support this. The Knowledge & Skills Framework (KSF) is an integral part of Agenda for Change which was introduced into the NHS in The KSF defines and describes the knowledge and skills staff need to deliver quality services. It provides a single, consistent and explicit framework on which to base staff development and reviews. As reported in the paper Valuing People Development of a Whole System Review (PDR) & Personal Development Plan (PDP) Improvement Plan 2016/17 there are now opportunities to enhance our processes and approaches towards embedding quality and meaningful PDR/PDP discussions for staff across the organisation. 1

23 Staff not covered by Agenda for Change have alternative systems in place. The Senior Managers Performance Management System has recently been reviewed and all senior managers have guidelines about the process and the requirement to have a personal development plan, with a particular focus on behavioural objectives. In relation to Consultants appraisal, clinical staff in Tayside have been trained in their appraisal process, reinforcing the principles and importance of appraisal and individuals job plans to meet with their revalidation requirements. The Medical Director provides reports to the Staff Governance Committee in relation to progress. 2.2 THERE IS A WORKFORCE LEARNING AND DEVELOPMENT STRATEGY IN PLACE During the last 12 months there have been a number of key development agendas progressed and the importance of strengthening the alignment of organisational development, leadership and staff development priorities is highlighted within the content of the People Matter Framework and NHS Tayside s Workforce Plan which sets out our priorities for the coming years. Evidence of the learning and development activity that has been taken forward during 2016 to support strategy is summarised in Appendix ALL STAFF HAVE EQUITY OF ACCESS TO TRAINING, IRRESPECTIVE OF WORKING ARRANGEMENTS OR PROFESSION NHS Tayside remains to be one of only two Health Boards in Scotland to have a Lifelong Learning Partnership Agreement in place which recognizes the commitment of NHS Tayside and Staff Organisations in supporting the learning and development of all its employees. With the Partnership now well established, a number of initiatives have been taken forward to ensure staff have equity of access to training. The NHS Tayside Lifelong Learning Partnership website has been created and provides information about diverse development opportunities. Through NHS Tayside s Lifelong Learning Partnership, there are national funds available via the Professional Bodies/Unions/Learning Representatives that can be accessed to support a variety of personal development needs. Examples of programmes include British Sign Language, Minute Taking, Dyslexia awareness and personal development to support individual s numeracy and literacy Skills. 2.4 RESOURCES, INCLUDING TIME AND FUNDING IS APPROPRIATELY ALLOCATED TO MEET LOCAL TRAINING AND DEVELOPMENT NEEDS Exchequer training and development budgets within NHS Tayside are devolved and managed locally to ensure that training budget expenditure is targeted at meeting organisational clinical service priorities. 2

24 To support staffs ongoing personal and career development a further tranche of funding of 250,000 was approved by NHS Tayside Board of Trustees in November 2014 and a group, chaired by the Chair of the Staff Governance Committee, oversees the application process and approval of requests. The principles of this education & training fund are to encourage staff to take up learning opportunities which will enhance service delivery and their personal development, with staff bands 2-5 being a key target group. Since the inception of the agreed funding in November 2014, 90 staff have been successful in securing funding. Six monthly reports on the detailed expenditure of this fund continue to be presented to NHS Tayside Board of Trustees. Figure 1 highlights the breakdown of percentage of monies by Staff Band approved since the fund s inception, and Figure 2 provides examples of courses supported. Figure 1: Breakdown of Expenditure from 2014 Fund 3

25 Figure 2: Individual Funding Approved from 2014 Fund per Staff Banding as a percentage of Funds Approved NHS Tayside sponsored 4 employees through the Education & Training Endowment Fund, to attend the "Young Scotland Programme The 3 day development programme`s core aim is to further personal development by promoting communication skills, build confidence and stretch minds and features the combination of debate, group discussions, presentations and thought provoking speakers. The feedback from the national co-ordinator of this programme reflected that our 4 participants had been excellent ambassadors for NHS Tayside and one of our employees was awarded for his presentation. Individual Learning Accounts (ILAs) are grants available to increase participation in adult learning and are awarded based on individuals personal circumstances. Funding of up to 200 is available to learners earning up to 22,000 per annum who wish to pursue a wide range of courses delivered by our local colleges. A number of employees have been successful in pursuing this opportunity. We will continue to embrace opportunities to work with our public, voluntary sector partners and local communities to ensure our workforce are equipped with the knowledge, skills and behaviours necessary to provide high quality services and person centred care. 3. RECOMMENDATIONS The Staff Governance Committee is asked to note the progress made against the Staff Governance Standard All Staff Are Appropriately Trained and Developed. 4

26 4. REPORT SIGN OFF George Doherty HR Director Jenni Jones Associate Director - Development Pat Millar Head of Knowledge & Skills March

27 Learning & Development Appendix 1 Introduction During 2016 there have been a number of achievements and initiatives taken forward by the Learning & Development Team. This section of the report aims to highlight/summarise some of the key successes and capture the activity of ongoing corporate agendas. Statutory/Mandatory Training NHS Tayside must ensure that it provides high quality services and care from professional staff who are engaged and supported by the organisation. In order to support this, staff s level of knowledge, skills and competence is paramount; this is reinforced within NHS Tayside s People Matter Strategic Framework and NHS Tayside s 5 year transformation programme work stream Workforce and Care Assurance NHS Boards have legal responsibilities to ensure staff receive training to develop the Knowledge & Skills required for a safe and healthy workplace (Garcey & Wilcock 2005) 1. Accountability and responsibility in relation to the statutory/mandatory training agenda is three-fold: The organisation as the employer, to provide the learning and development programmes. The line manager to ensure support and protected time for the employee to undertake identified learning needs and to record completion of all statutory/mandatory training as part of the annual PDR/PDP process. The individual employee to undertake the required learning as identified within their PDP, record activity of learning and to apply the learning in practice. The increasing requirement for all groups of staff to undertake a plethora of statutory/mandatory training programmes, against competing priorities, makes it challenging to identify protected learning time to complete these programmes. Staff and managers have expressed the need to have clarity regarding what constitutes statutory and mandatory training and the importance of acknowledging existing knowledge, experience and evidence of competence in order to ensure that all staffs time is used productively. Nationally, a working group is in place, sponsored by all NHS Board s HR Directors, to examine Statutory and Mandatory training across the Boards, its remit being to: Remove, or at least reduce, duplication of training when staff move from location to location to promote the once for Scotland model Reduce time away from service, whilst maintaining safety and corporate governance responsibilities and maintaining and improving the quality of learning Have an agreed generic Statutory/Mandatory core training framework in place, to cover all NHS Scotland staff with agreed learning standards and outcomes across Boards. Ensure staff know their personal and professional responsibilities for accessing statutory and mandatory training opportunities 1 Garcey & Wilcock

28 Over the last 12 months this work has progressed with the following 9 core topics having been identified and agreed. Presentations to relevant national networks have taken place to obtain their agreement and commitment to this model. The subject areas being: Equality, Diversity & Human Rights Health, Safety and Welfare Fire Safety Infection Prevention and Control Manual Handling Violence and Aggression (Personal Safety Awareness) Information Governance Public Protection (includes Adult and Child Protection) Resuscitation (summoning clinical assistance) To ensure these training programmes are aligned with key organisational objectives, person centred care, patient safety and linked to individuals jobs, a resource to facilitate identification and agreement of mandatory training programmes has been developed in the format of the Statutory/Mandatory Training Directory (document embedded below) Stat and Mand Trg Directory and Accoun To provide the Staff Governance Committee with an assurance regarding reporting systems on Statutory/Mandatory training activity, the LearnPro system and NHS Tayside s Training Database are our current systems in use for recording compliance rates. Data can be accessed by managers for their areas of responsibility on the 9 core areas of training. This 9 Core Areas of Training reporting model has been tested and is now being rolled out within the HR OD Directorate. Corporate Induction Programmes Corporate Welcome programmes continue to be offered on a twice weekly basis to welcome new staff to NHS Tayside. The programme sets the scene for new staff joining NHS Tayside and highlights our strategic aims objectives, vision and values, via a number of interactive presentations. A positive addition to the programme is the Chief Operating Officer s commitment to attend these and to deliver a welcoming session. Group sessions raise awareness of key policies including health and safety, clinical, staff and information governance, infection control, partnership working, learning and development opportunities. Within NHS Tayside s Induction Policy, a local induction checklist is provided for all new staff and their line managers to complete as part of their induction phase. A total of 887 new staff attended programmes during 2016 and the programme continues to receive good feedback from both attendees and from managers. 7

29 Outcomes Achieved An evaluation project has been in place for the last 6 months to gauge new employee s experiences during their induction period. This demonstrates positive feedback and highlights a high percentage of new employees feel valued and welcomed during their induction phase in NHS Tayside. The identification and development of compulsory LearnPro modules for all staff ensures clear understanding of what learning staff must undertake upon commencement of employment, ensuring a safe and healthy environment. Equality & Diversity Programmes Equality and Diversity training programmes continue to be delivered across NHS Tayside to assist with understanding of current legislation, policies and procedures. Programmes have been designed to meet a range of requirements and consist of a variety of programmes, which include: Monthly Certificate to Recruit programmes Generic programmes for staff based around the requirements of evidencing the indicators within the KSF Core Dimension on Equality and Diversity Diversity & Equality Champions is a two day programme for staff who wish to be champions. We now have 165 Champions trained in NHS Tayside. ½ day Awareness sessions Interpretation & Translation Awareness sessions Sensory Awareness sessions have now been included in Manual Handling programmes A one hour programme, specifically for Foundation Year doctors entering the organisation with the opportunity to explore a specifically designed scenario to raise awareness of discrimination and to assist with identifying and challenging discrimination. Planning for Your Future in Retirement NHS Tayside in Partnership with the Scottish Pre Retirement Council provides courses for all staff on Planning for your future in Retirement. These seminars provide participants with information and guidance on how to plan for all aspects of retirement, including topics such as finance, planning, health and wellbeing and volunteering opportunities. During 2016, 6 Pre Retirement courses have been delivered across Perth, Dundee and Angus, with NHS Tayside employees having attended from across all staff groups. Due to the changing demographics of the workforce, additional Pre Retirement programmes have been scheduled in 2017 to meet demand. 8

30 Lifelong Learning Partnership Programmes During 2016 NHS Tayside s Lifelong Learning Partnership Group has continued to promote and provide a number of development programmes. Examples include Dyslexia Awareness workshops, to heighten understanding of the issues relating to dyslexia, help identify coping strategies and raise awareness of support mechanisms available in the workplace. Other training programmes included Minute taking (see picture below) These programmes proved to be very well received and the partnership working that enabled this training to take place across all localities is to be commended. LearnPro LearnPro has now been in use in NHS Tayside for over 4 years and to-date has just over 11,500 staff registered on the system and more than 10,500 actively using e-learning to develop their knowledge and skills in a variety of subject areas. NHS Tayside embraces e-learning as an opportunity to support learning through the use of information technology. E-learning can provide large scale online delivery of modules and courses such as the compulsory/mandatory training required to be completed by all NHS Tayside staff. Currently there are more than 160 modules available covering a wide range of subjects including health and safety, infection control and all the core learning modules identified for the wider workforce. LearnPro is fully funded until March 2018 and following a reassessment of our internal skill set we now have support to maintain, design and develop future modules. NHS Tayside is part of the national LearnPro group for all NHS Scottish Boards and has the opportunity to influence recommendations and suggest changes to the system. Outcomes Achieved Aspects of staff s learning needs are met as a result of the range of learning and development modules. LearnPro activity reports are available to line managers for all staffs LearnPro activity. 9

31 Work Experience for School Pupils The Enabling Work Experience Procedure for school pupils continues to be facilitated within NHS Tayside by the Learning and Development Team. Feedback from interested parties remains positive and relationships with colleagues working in education and schools continue to be very successful. During the academic year 2016 a total of 678 placements across diverse disciplines and departments have been arranged by the Learning & Development Team across NHS Tayside. Work this year will continue to refine the work experience process and to increase opportunities available for school pupils across clinical and non clinical areas. Outcomes Achieved The processes in place to support work experience have been reviewed to maintain contemporary approaches for work experience opportunities. Keep in touch meetings have been held with local authority education colleagues, to review work experience opportunities and maintain effective placements for future pupils. This agenda is crucial as it supports longer term workforce and succession planning across NHS Tayside. Healthcare Support Workers The Mandatory Induction Standards and Code of Conduct for Healthcare Support Workers and Mandatory Code of Practice for Employers of Healthcare Support workers came into effect on the 1 st of January NHS Tayside continues to maintain a system for identifying and supporting all new Healthcare Support Workers and monitoring their progress against the completion of the Induction Standards. In conjunction with our HR colleagues, all managers of new starts are contacted before their start date with relevant learning materials, an Induction date and an offer of support are given on a 1:1 basis as required. Thereafter managers are responsible for ensuring that their members of staff adhere to the Code of Conduct through the KSF Review process. Currently within NHS Tayside the timeframe for implementation of the Code of Conduct for new staff is 3 months. 10

32 Outcomes Achieved NHS Tayside has been instrumental in influencing the national way forward for Healthcare Support Worker standards and code of conduct. Managers and staff have been supported in completing the standards from recruitment and throughout the induction process and we are currently recording a 92% compliance rate. Certificate to Recruit Monthly Certificate to Recruit Workshops continue to be delivered across the organisation to support line managers with their personal development and skills required to support values based recruitment. During 2016 the programme was reviewed and updated to reflect the importance of a values based approach to our recruitment practices. Health Behaviour Change programmes Health Behaviour Change programmes continue to be delivered and Return on Investment evaluations are in place. Refresher courses, Health Behaviour Change Level 2 courses, Health Behaviour Change Awareness sessions as well as a carers Health Behaviour Change session have taken place during 2016, all receiving excellent feedback and demonstrating of evidence of impact on supporting people with long term conditions. Sage & Thyme courses The highly successful Sage & Thyme training programmes that were introduced 3 years ago continue to be delivered. This is an evidenced based approach programme to enable practitioners to engage with patients / service users / carers who are in distress, and it provides a framework for practitioners to engage with, identify concerns, support the person to manage their distress and bring the conversation to a conclusion. The courses are being very positively evaluated with staff reporting increased willingness and confidence supporting people who are in distress. To date 412 staff have attended programmes. Following the continued success of the Sage & Thyme Communication Skills Programmes. NHS Tayside has committed to a further 10 courses to support staff and teams in undertaking this programme during

33 NHS Tayside Education & Training Endowment Fund In November 2014, Tayside NHS Endowment Fund Board of Trustees agreed to designate 250,000 of funds for an Education & Training Fund and the NHS Tayside Education & Training Group has continued to meet on a quarterly basis to consider applications from NHS Tayside employees to support their personal development. The following key operating principles for the fund were agreed by Trustees:- The Fund would not be principally used for core technical skills. It would focus on helping staff develop caring, compassionate and person centred skills necessary for the effective care of patients The Fund would be weighted towards supporting lower band employees, with >60% of the fund directed to Agenda for Change staff on bands 2 to 5. Trustee Members of the Education & Training Endowment Fund Group have delegated authority to approve funding requests and report to Board of Trustees on a six monthly basis The principles of this education & training fund are to encourage staff to embark on a learning programme which would enhance their personal development, with non traditional learners very much being a key target group. Monitoring the impact this Endowment Fund has had on individuals, teams and service delivery across NHS Tayside is vital, and on completion of programmes, applicants are asked to share their learning via routes appropriate to the individual. This course has really helped my personal development because I feel a lot more confident in presenting and communicating Band 2 member of staff 12

34 Young Scotland Programme 2016 Funding was also approved in May 2016 to support four members of staff to attend the Young Scotland Programme This 3-day development programme s core aim is to further personal development by promoting communication skills, build confidence and stretch minds and features the combination of debate, group discussions, presentations and thought provoking speakers. The feedback from the national co-ordinator of this programme reflected that our 4 participants had been excellent ambassadors for NHS Tayside and indeed one of our participants was awarded a Highly Commended Certificate (see pictures above). New Initiatives and Achievements in 2016 Glasgow Centre for Inclusive Living Glasgow Centre for Inclusive Living (GCIL) is a user lead organisation that has been delivering a wide range of services provided by disabled people for disabled people and is designed to empower individuals to assert more control over their lives. GCIL Equality Academy has built and expanded on its very successful positive action graduate traineeship programme for disabled people with the development of a strong partnership which includes the Scottish Government and NHS Scotland. NHS Tayside is actively involved in supporting this important initiative and is benefiting greatly from the expertise and experience of all parties involved. Business & Administration Career Pathway Group Within NHS Tayside we have been working closely with colleagues at NES (National Education Scotland) to establish a structure to enable staff who work in Business & Administration roles to shape and influence their own learning and career development and a number of colleagues have undertaken SVQ qualifications. The group have been actively involved in enhancing local networks which will provide a stronger professional identity and increase awareness of the vital contribution Business & Administration staff make to the delivery of safe and effective Person Centred Care. Cancer Module Development During 2016 a project group was established to support the Multidisciplinary Cancer Audit Team as there was a development need identified to support non-clinical staff who were working in Cancer Audit data collection roles. The project aims were to develop an innovative CPD Programme which would enhance participants understanding of terminology used by clinicians during Cancer Audit MDT meetings, the importance of their roles in recording accurate data and the impact this has on improving our Cancer Care Services/Treatment for patients. This programme has been developed to 13

35 facilitate a key NHS Clinical priority regarding performance targets in Cancer across all NHS Boards and is a major element of the Cancer Strategy. We look forward to full implantation during Facilities Skills Career Programmes Following the success of previous Facilities Skills Career Map Programmes a further 3 cohorts have run during staff from Site Support Services at Perth Royal Infirmary have recently completed a 5 week Facilities Skills Management course covering topics such as IT access, EKSF, , Core Work Skills, CV and Job Applications to support and encourage learning and career development. This course was developed in partnership with staff colleagues, NES and Health Facilities Scotland to implement the Facilities Skills Map which provides a framework to support staff, meet their learning needs and develop career pathways. The course also complements the People Matter Strategic Framework as one priority is to Develop a Capable Workforce by supporting staff to do their job to the best of their ability. The programmes have resulted in a number of very positive outcomes with several participants being successful in receiving secondment opportunities, securing promoted posts and undertaking further courses of study. A further 2 cohorts are currently being planned for roll out during Organisational Development Programmes A wide range of programmes and interventions have been undertaken by the Organisational Development team seeking to enhance culture and relationships. Programme No of participants (Improvement Academy) Courageous Conversations 113 Building Effective Relationships 55 Giving & Receiving Feedback 10 Recognition Matters 9 Total 187 Bespoke Facilitation: This has been undertaken for the following groups: Gastroenterology Arbroath Renal Satellite Unit Dental Hospital Senior Nurses - Stracathro NICU 14

36 Chaplaincy GMC ACF Conference Transformation Workstream events Crucial Accountability Two members of staff attended Crucial Accountability training and one proceeded to Train the Trainer training in conjunction with NHS Forth Valley. Following the taught part of the accreditation liaison was undertaken with NHS Grampian to cofacilitate on three North East Learning Collaborative (NELC) sessions in order to gain accreditation within required time. Informal/initial feedback from these sessions has been positive. NHS Tayside Coaching Service 47 people had coaching from 17 coaches in of these completed their coaching within 2016 with 18 continuing into 2017.There was a total of 204 hours coaching related interventions provided. Analysis of the evaluations of coaching completed in 2016 is still to be completed. Team Coaching Four members of the team have undertaken training to become accredited Aston Team Coaches and are currently providing development support to ten teams. Plans for building capacity to support more teams are being developed. Leadership/Management Courses Leading with Purpose North Region Clinical Leadership Programme This regional programme was launched this year and is designed for clinicians currently in clinical lead roles and clinicians aspiring to clinical lead roles who are also Hospital Consultants, General Practitioners or Dentists. The programme is delivered over three sessions (2 x 2 day & a final 1 day session). Participants are taken through the following topics: National Context Introduction to Leadership Culture and Climate Self Awareness and Insight Leading Teams Leading Change Personal Resilience National and local strategic direction Reflections on progress and personal actions Review of Learning There have been 14 consultant staff / general practioners from Tayside that have participated in this programme. Promoting Leadership Leaders have a pivotal role to play in the effective functioning of health care systems through engaging the clinical workforce in the delivery of high quality services. Effective leadership has a profound impact on the quality of patient care that is delivered. Leadership roles offer an opportunity to make a real difference to the care provided for patients across a department, directorate and the whole system. However, the roles can be difficult and frustrating, fraught with cultural and professional challenges. We recognise that a leader s role requires a particular skill set which differs, at least in part, from that required to undertake a purely clinical or managerial role. NHS Tayside regards the development of its leaders as fundamentally important to deliver strategic objectives. The organisation is committed to supporting leaders in identifying their development needs and building their leadership capability and capacity so that they are enabled to undertake their role effectively. 15

37 There have been two cohorts made up of 196 leaders, both clinical and non-clinical who have participated throughout programme. ILM Programmes The Leadership and Management Team currently deliver three qualifications from the Institute of Leadership & Management (ILM) Curriculum Introduction to Team Leader, Level 3 in Leadership & Management and SVQ in Leadership & Management. These programmes are all available to new and current managers and leaders within the organisation. The predicted outcomes of the programmes include confident first line managers, better relationships and communication in teams and leaders working with improved alignment with organisational goals. Introduction to Team Leader The Introduction to Team Leader Programme is a week-long programme covering topics such as leadership, assertiveness, motivation, service improvement, HR, performance management and customer care. Three programmes were delivered during 2016/17, with 36 participants completing the programme. Participants came from nursing, surgical directorate, medical directorate, access directorate, corporate services, public health, mental health and the CHP s. Level 3 in Leadership & Management This qualification is targeted towards individuals with management responsibilities but no formal training, and particularly those seeking career development opportunities. The qualification incorporates the following areas: Core management skills such as understanding how to organise and delegate Ability to perform management tasks manage projects, lead meetings Team leadership e..g. how to motivate people to improve performance Change and innovation plan and manage change, create a culture of innovation A full range of communications skills Managing people and relationships negotiation, networking, building relationships Leadership understand leadership, use action learning to develop your leadership capabilities. The programme was delivered once during 2016/17, with 21 participants completing the programme. SVQ level in Leadership & Management This qualification is targeted towards individuals in a first management role, or those with management responsibilities but no formal training. The SVQ comprises of four mandatory units and three optional units. The four mandatory units are: Manage your own resources and professional development Provide leadership for your team Allocate and monitor the progress and quality of work in your area of responsibility Ensure health and safety requirements are met in your area of responsibility The suite of optional units include skills to encourage innovation; plan and implement change; develop productive working relationships; deal with recruitment; manage a budget or a project; and help to improve or solve problems with customer service. The programme was delivered once during 2016/17, with 7 participants currently completing the programme. Examples of the feedback from the ILM Programmes include: I will put into practice the motivational steps to help keep staff well informed and to boost 16 morale Better managerial techniques

38 Intervention (Short) Programmes Licensed Programmes The Leadership & Management Team deliver a range of licensed programmes to meet the needs of NHS Tayside staff. 7 Habits of Highly Effective People The 7 Habits of Highly Effective People workshop provides the foundation to strengthen the human side of performance at the personal, managerial, and organsational levels. Based on the best-selling business book by the same name, this three-day workshop equips staff with the tools and skills to work at the highest levels of effectiveness with and through others. The course helps build stronger organisations by strengthening and exercising the character and competence of the individuals within them. Participants learn how to take initiative; balance key priorities; improve interpersonal communication; leverage creative collaboration; and apply principles for achieving a balanced life. Potential organisational impact includes increased productivity; improved communication; strengthened relationships; increased influence; and focus on critical priorities. Outcomes Achieved The Seven Habits of Highly Effective People Programme has been delivered 2 times during 2016/17, with 24 participants completing the programme. Participants included staff from medicine directorate, surgery directorate, access directorate, public health, CHP s, Public health and Operations Directorate. Feedback included: I plan to concentrate on being proactive and listening, and the emotional bank account in first instance To think before acting; to listen to others and not interrupt Most valuable: The different approaches that you can take for scenarios and how to overcome these differently. I like the way in which the Programme makes you look at yourself critically followed by how you can make improvement in your effectiveness It gave me an insight into what my strengths, weaknesses are and how I can go about overcoming or strengthening them Action Centred Leadership The Action Centred Leadership Programme is based on the philosophy of Adair Leadership Development. It recognises that three broad levels of leadership are merging (team, operational and strategic), that excellence is required at all three levels, and that the secret to business success lies in teamwork between and within each of these levels. The Action Centred Leadership model enables managers to reflect on their personal impact and supports them to explore the balance between the three levels. Outcomes Achieved Three programmes have been delivered during 2016/17 to 38 participants. Participants have included representatives from Medicine Directorate, Access Directorate, Corporate Directorate, Mental Health and Public Health. Feedback included: Understanding how you perceive others. Putting skills into practical application. 17 Observing group dynamics

39 Learning about the leadership role and identifying leadership functions and needs. Really enjoyed how the tasks demonstrated aspects of these skills within a controlled environment. Learning and practicing how to deal with tasks, groups, individuals Looking at leadership skills and how to make the most of team and individual motivation. Also, the importance of taking a step back to appraise everything which is going on. Not to get caught up in the task!!! Local Short Programmes The Licensed programmes are complemented by a suite of locally developed short programmes to meet the needs of our staff. A review of the content of each programme has been carried out to ensure that they are contemporary, fit for purpose and provide participants with a range of knowledge, skills, tools and techniques to support them in their role. Content has been mapped against KSF levels for the staff groups most likely to be attending the programmes and delivery methods have been updated to reflect contemporary views on management learning and to optimise time spent face to face in the training room. Programme No of sessions Total No of participants Assertiveness Skills 2 29 Performance Management 2 30 Presentation Skills 2 14 Resilience For Leaders 3 29 Values Based Leadership 3 30 TOTAL Outcomes Achieved Leadership and Management programmes were well received by participants. Evaluation data collected included positive feedback on the style and tone of the workshops as well as the relevance of the content. Examples of feedback on the programmes included: It is OK to say no it is OK to take time to answer / meet / react etc. Big myself up more in internal conversations The three steps to assertiveness will be useful, particularly listening and reflecting back to staff. This is relevant just now to me as we are about to go through organisational change Give staff autonomy develop themselves. Staff can take ownership and contribute to their own management 18 Learning how to respond to people correctly using correct tone etc. listen more

40 A reminder of choosing my attitude sometimes this is not so easy when dealing with the public. That I can choose to be happy at work and my moods affect th 19

41 Future Initiatives for 2017/18 The Development of an NHS Tayside Practice Development Network The International Practice Development School (PD) was first delivered in NHS Tayside in autumn 2015; this initiative was led by the Nursing & Midwifery Directorate. Leads and nominated members of Improvement and Development Teams were invited to participate in order to develop a shared understanding of PD and to develop a community of practice able to facilitate person centred cultures that will enhance staff and patient outcomes. An in-depth evaluation to understand the impact of PD School took place during July and August 2016 and included focus groups, individual interviews and case study reports. The findings indicate that the school was very positively evaluated and individuals found that it enhanced their skills and confidence in facilitating practice. The PD Network will continue to develop good practice and provide ongoing support for practice development across the organisation. Future Organisational Development programmes and offerings will informed by and aligned to the culture development agenda that has been undertaken in recent months and will reflect the findings and key actions that this informs. Conclusion There has been a sustained effort in the last year to use our learning and development resources to best effect in addressing the organisation s priorities whether through change, policy development, leadership or learning and development solutions. Capacity can and will continue to be a challenge in meeting needs but it will also drive creativity in developing blended learning approaches, simplifying policy and reinforcing the importance of working with others to achieve long term substantive improvements across our workforce. The year ahead will provide us with many exciting challenges and opportunities with the Health & Social Care Integration agenda and NHS Tayside s Transformation Programmes being at the forefront of driving the change agenda. This will require strong leadership and commitment to the workforce development agenda. Key national and local strategic drivers will continue to provide us with a clear steer towards achieving our main aims and with imatter now firmly established within NHS Tayside this provides us with a strong platform to build on future workforce development initiatives. 20

42 DRAFT STATUTORY/MANDATORY TRAINING DIRECTORY Statutory Training Programmes are training programmes that NHS Tayside are legally required to provide as defined in law and covered by a statutory instrument (e.g. Health & Safety at Work etc. Act 1974 and its subsequent regulations, for example: Display Screen Equipment, Manual Handling Regulations, Fire Safety) or where a statutory body has instructed organisations to provide training on the basis of legislation (e.g. training on equalities issues such as Race Equality is required because the Commission for Racial Equality has interpreted the Race Relations Amendment Act as saying that training should be provided to meet the legislation). Mandatory Training Programmes are training programmes that have been determined by NHS Tayside. Mandatory training is concerned with providing assurance against the implementation of policies and the provision of training to enable employees to carry out the requirements of their job role safely and effectively and maintain their competence to required standards. 1. This document has been produced to support corporate and professional ownership of the statutory/mandatory training agenda and has been set out to reflect alignment with NHS Tayside s policies as listed currently* on NHS Tayside s Staffnet under the following headings: Group 1 Clinical Policies (including Infection Prevention & Control) Group 2 Finance & Governance Policies Group 3 Nursing & Midwifery Policies Group 4 Operational/Facilities Policies Group 5 Risk, Health & Safety (including Fire Safety) Policies Group 6 Human Resources Policies Please note the following 9 topics are actively being considered as core areas of training for all NHS employees: Equality, Diversity & Human Rights Infection Prevention & Control Information Governance Health, Safety & Welfare Manual Handling Public Protection (Child & Adult) Fire Safety Violence & Aggression (personal safety, de-escalation) Resuscitation (summoning help) 2. In addition to the policies listed, there are many role specific mandatory training, clinical skills and e-system programmes that staff are required to complete, these should be identified as part of the appropriate KSF/PDR/PDP appraisal process and be relevant to individual s roles/responsibilities. 3. This document should be referred to when identifying staff s training needs, as part of the PDR/PDP process and can be used in conjunction with any relevant occupational standards, competencies, role specific workbooks. 4. To ensure robust governance and lines of accountability, monitoring of training activity will be aligned with NHS Tayside s Clinical and Care Governance Committee reporting structures. Implementation in practice is set out in Appendix 1. *N.B. due to the changing nature of policy development, it is important to note the flexibility of this document C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v

43 GROUP 1 CLINICAL POLICIES TOPIC/POLICY Cardiopulmonary Resuscitation Carers Policy TRAINING STATUS e.g. Core - relevant for all staff (Blue) Role/Discipline/individual (Red) Departmentally Agreed (Yellow) DURATION OF TRAINING (if applicable) BLS 2 hours ALS 2 days ILS 1 day TRAINING DELIVERY FORMAT/ REGULARITY OF TRAINING (to be assessed on an annual basis during Personal Development & Planning process) Face to face Face to face Face to face METHOD OF RECORDING AND REPORTING COMPLETION OF TRAINING/INFORMATION GIVEN LearnPro NHS Tayside Training Database Local Reporting Systems Policy Tracker Tool eksf NHS Tayside Training Database NHS Tayside Training Database NHS Tayside Training Database Caring for In Patient After Death ½ hour Face to Face (Medical Induction) Local Reporting Systems Child Protection Case Supervision Policy Child Protection Policy Dignity & Privacy (Single Sex Accommodation) Disposal of Foetal Remains of Less than 24 Weeks Epidural Infusion Analgesia Policy Level 3-2 Days Face to face Level 1-40 mins. Level 2-3 hrs LearnPro Module Face to face - Reading Policy/ Awareness 2 NHS Tayside Training Database LearnPro NHS Tayside Training Database Policy Tracker Tool - Face to Face Local Reporting Systems - Clinical Skills Pack Local Reporting Systems C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v

44 TOPIC/POLICY Establishing Patient Identity Food, Fluid and Nutritional Care (Adults) General Radiation (Health & Safety) TRAINING STATUS e.g. Core - relevant for all staff (Blue) Role/Discipline/individual (Red) Departmentally Agreed (Yellow) DURATION OF TRAINING (if applicable) TRAINING DELIVERY FORMAT/ REGULARITY OF TRAINING METHOD OF RECORDING AND REPORTING COMPLETION OF TRAINING/INFORMATION GIVEN LearnPro NHS Tayside Training Database (to be assessed on an Local Reporting Systems annual basis during Policy Tracker Tool Personal eksf Development & Planning process) 40 mins LearnPro Module LearnPro Maternal & Infant Nutrition 2 days MUST - ½ day Face to Face Face to Face Local Reporting Systems Local Reporting Systems - Face to Face Local Reporting Systems Immunisation Policy Independent Advocacy Policy/ Adult Support & Protection (People Protection) Infection Prevention and Control Policy 2 x 1 hr 40 mins (various specific Infection Control programmes) - Reading Policy/ Awareness - Reading Policy/ Awareness Face to face LearnPro Module 3 Policy Tracker Tool Policy Tracker Tool NHS Tayside Training Database eksf C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v

45 TOPIC/POLICY Informed Consent Policy Interpretation & Translation Interventional Procedures Intimate Personal Care and Chaperoning Introduction and Management of Point of Care Testing Schemes Ionising Radiation Medical Exposure (Health & Safety) TRAINING STATUS e.g. Core - relevant for all staff (Blue) Role/Discipline/individual (Red) Departmentally Agreed (Yellow) DURATION OF TRAINING (if applicable) ½ hour TRAINING DELIVERY FORMAT/ REGULARITY OF TRAINING (to be assessed on an annual basis during Personal Development & Planning process) Good Practice Guidelines Bespoke training with teams METHOD OF RECORDING AND REPORTING COMPLETION OF TRAINING/INFORMATION GIVEN LearnPro NHS Tayside Training Database Local Reporting Systems Policy Tracker Tool eksf eksf 40 mins LearnPro Module LearnPro Local Reporting Systems - Face to Face Local Reporting Systems eksf 1day Face to face Local Reporting Systems - Face to Face Local Reporting Systems - Face to Face Local Reporting Systems eksf Ionising Radiation Policy Face to Face Local Reporting Systems eksf 4 C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v

46 TOPIC/POLICY Laser Safety (Health & Safety) TRAINING STATUS e.g. Core - relevant for all staff (Blue) Role/Discipline/individual (Red) Departmentally Agreed (Yellow) DURATION OF TRAINING (if applicable) TRAINING DELIVERY FORMAT/ REGULARITY OF TRAINING (to be assessed on an annual basis during Personal Development & Planning process) - Face to Face Local Reporting Systems METHOD OF RECORDING AND REPORTING COMPLETION OF TRAINING/INFORMATION GIVEN LearnPro NHS Tayside Training Database Local Reporting Systems Policy Tracker Tool eksf Latex Policy (Health & Safety) Magnetic Resonance Imaging Safety Policy (Health & Safety) - Face to Face NHS Tayside Training Database - Face to Face Local Reporting Systems eksf Medicines Reconciliation Policy - Reading Policy/ Awareness Policy Tracker Tool 5 C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v

47 TOPIC/POLICY Misconduct in Research TRAINING STATUS e.g. Core - relevant for all staff (Blue) Role/Discipline/individual (Red) Departmentally Agreed (Yellow) DURATION OF TRAINING (if applicable) TRAINING DELIVERY FORMAT/ REGULARITY OF TRAINING (to be assessed on an annual basis during Personal Development & Planning process) - Reading Policy/ Awareness METHOD OF RECORDING AND REPORTING COMPLETION OF TRAINING/INFORMATION GIVEN LearnPro NHS Tayside Training Database Local Reporting Systems Policy Tracker Tool eksf Policy Tracker Tool Non Medical Prescribing Policy - Reading Policy/ Awareness Policy Tracker Tool Patient Equipment Management Policy - Reading Policy/ Awareness Policy Tracker Tool Patient Group Directive Reading Policy/ Awareness Policy Tracker Tool Patient Specific Directive Reading Policy/ Awareness Policy Tracker Tool Policy for the Provision of Intra- Operative Cell Salvage 40 mins LearnPro Module LearnPro 6 C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v

48 TOPIC/POLICY Policy on the Management of Substance Misuse on NHS Tayside Premises TRAINING STATUS e.g. Core - relevant for all staff (Blue) Role/Discipline/individual (Red) Departmentally Agreed (Yellow) DURATION OF TRAINING (if applicable) TRAINING DELIVERY FORMAT/ REGULARITY OF TRAINING (to be assessed on an annual basis during Personal Development & Planning process) - Reading Policy/ Awareness METHOD OF RECORDING AND REPORTING COMPLETION OF TRAINING/INFORMATION GIVEN LearnPro NHS Tayside Training Database Local Reporting Systems Policy Tracker Tool eksf Policy Tracker Tool Prescribing of Medicines that Are Non Formulary - Reading Policy/ Awareness Policy Tracker Tool Prophylaxis of Venous Thromboembolism - Clinical Skills Pack Face to Face Local Reporting Systems Respiratory Mask Fit Test 1 hour Face to Face Local Reporting Systems Safe Use of Equanox/Entonox for Short Term Pain Relief - Face to Face Clinical Skills Local Reporting Systems eksf 7 C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v

49 TOPIC/POLICY Subcutaneous Administration of Medicines by the T34 Ambulatory Syringe Pump TRAINING STATUS e.g. Core - relevant for all staff (Blue) Role/Discipline/individual (Red) Departmentally Agreed (Yellow) DURATION OF TRAINING (if applicable) 2½ hours TRAINING DELIVERY FORMAT/ REGULARITY OF TRAINING (to be assessed on an annual basis during Personal Development & Planning process) Clinical Skills Pack Face to face METHOD OF RECORDING AND REPORTING COMPLETION OF TRAINING/INFORMATION GIVEN LearnPro NHS Tayside Training Database Local Reporting Systems Policy Tracker Tool eksf Local Reporting Systems Local Reporting Systems Summoning Clinical Assistance Outwith Clinical Areas Use of Blood and Blood Components - Face to Face NHS Tayside Training Database 60 minutes LearnPro Module LearnPro Verification of Expected Death - Clinical Skills Pack Local Reporting Systems eksf 8 C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v

50 GROUP 2 FINANCE & GOVERNANCE POLICIES TOPIC/POLICY Data Protection Policy TRAINING STATUS e.g. Core - relevant for all staff (Blue) Role/Discipline/individual (Red) Departmentally Agreed (Yellow) DURATION OF TRAINING (if applicable) TRAINING DELIVERY FORMAT/ REGULARITY OF TRAINING METHOD OF RECORDING AND REPORTING RE COMPLETION OF TRAINING/INFORMATION GIVEN LearnPro NHS Tayside Training Database (to be assessed on an Local Reporting Systems annual basis during Policy Tracker Tool Personal eksf Development & Planning process) 40 mins LearnPro LearnPro Equality Impact Assessment - Reading Policy/ Awareness Policy Tracker Tool Health Fund Policies & Procedures Information Governance - Reading Policy/ Awareness 40 mins LearnPro LearnPro Policy Tracker Tool Lease Car Policy - Reading Policy/ Awareness NHS Tayside - Reading Policy/ Access Policy Awareness Patient Access and Waiting Times Management Overpayment of Salaries, Wages and Allowances - Reading Policy/ Awareness 9 Policy Tracker Tool Policy Tracker Tool Policy Tracker Tool C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v

51 TOPIC/POLICY Ownership and Exploitation of Intellectual Property Photography and Video Recordings of Patients for Clinical and Service Use Policy Development, Review and Control Policy Records Creation and Registration Records Management Policy Records Retention Schedules System Access Policy TRAINING STATUS e.g. Core - relevant for all staff (Blue) Role/Discipline/individual (Red) Departmentally Agreed (Yellow) DURATION OF TRAINING (if applicable) TRAINING DELIVERY FORMAT/ REGULARITY OF TRAINING (to be assessed on an annual basis during Personal Development & Planning process) - Reading Policy/ Awareness - Reading Policy/ Awareness - Reading Policy/ Awareness 40 mins LearnPro LearnPro 40 mins LearnPro LearnPro 40 mins LearnPro LearnPro - Reading Policy/ Awareness METHOD OF RECORDING AND REPORTING RE COMPLETION OF TRAINING/INFORMATION GIVEN LearnPro NHS Tayside Training Database Local Reporting Systems Policy Tracker Tool eksf Policy Tracker Tool Policy Tracker Tool Policy Tracker Tool Policy Tracker Tool 10 C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v

52 TOPIC/POLICY Use of and Network Services Use of Portable Computers and Removable Media TRAINING STATUS e.g. Core - relevant for all staff (Blue) Role/Discipline/individual (Red) Departmentally Agreed (Yellow) DURATION OF TRAINING (if applicable) ½ hr (Induction) 1½ hr (IT Dept) TRAINING DELIVERY FORMAT/ REGULARITY OF TRAINING (to be assessed on an annual basis during Personal Development & Planning process) Face to Face Face to face 40 min LearnPro LearnPro METHOD OF RECORDING AND REPORTING RE COMPLETION OF TRAINING/INFORMATION GIVEN LearnPro NHS Tayside Training Database Local Reporting Systems Policy Tracker Tool eksf NHS Tayside Training Database NHS Tayside Training Database 11 C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v

53 GROUP 3 NURSING & MIDWIFERY TOPIC/POLICY TRAINING STATUS e.g. Core - relevant for all staff (Blue) Role/Discipline/individual (Red) Departmentally Agreed (Yellow) DURATION OF TRAINING (if applicable) TRAINING DELIVERY FORMAT/ REGULARITY OF TRAINING (to be assessed on an annual basis during Personal Development & Planning process) METHOD OF RECORDING AND REPORTING RE COMPLETION OF TRAINING/INFORMATION GIVEN LearnPro NHS Tayside Training Database Local Reporting Systems Policy Tracker Tool eksf Admin of Conscious Sedation Infant Feeding Policy - Clinical Skills Pack Local Reporting Systems - Face to face Local Reporting Systems Nursing/Midwifery Bank and Agency Policy Patient Observation and Engagement Pressure Ulcer Prevention and Care for Adults in the Community Pressure Ulcer Prevention and Care of Adult in Hospital - Reading Policy/ Awareness - Reading Policy/ Awareness C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v Policy Tracker Tool Policy Tracker Tool 2 hours Face to face Local Reporting Systems 2 hours Face to face Local Reporting Systems Records and - Clinical Skills Local Reporting Systems

54 TOPIC/POLICY TRAINING STATUS e.g. Core - relevant for all staff (Blue) Role/Discipline/individual (Red) Departmentally Agreed (Yellow) DURATION OF TRAINING (if applicable) TRAINING DELIVERY FORMAT/ REGULARITY OF TRAINING (to be assessed on an annual basis during Personal Development & Planning process) METHOD OF RECORDING AND REPORTING RE COMPLETION OF TRAINING/INFORMATION GIVEN LearnPro NHS Tayside Training Database Local Reporting Systems Policy Tracker Tool eksf Record Keeping Rostering Policy for Nursing & Midwifery Staff Spiritual Care Policy Use of Bedrails Pack - Face to face Local Reporting Systems - Face to face NHS Tayside Database Read Policy/ Awareness Policy Tracker Tool 13 C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v

55 GROUP 4 OPERATIONAL/FACILITIES POLICIES TOPIC/POLICY Adult Missing Patient Policy TRAINING STATUS e.g. Core - relevant for all staff (Blue) Role/Discipline/individual (Red) Departmentally Agreed (Yellow) DURATION OF TRAINING (if applicable) TRAINING DELIVERY FORMAT/ REGULARITY OF TRAINING (to be assessed on an annual basis during Personal Development & Planning process) - Reading Policy/ Awareness METHOD OF RECORDING AND REPORTING RE COMPLETION OF TRAINING/ INFORMATION GIVEN LearnPro NHS Tayside Training Database Local Reporting Systems Policy Tracker Tool eksf Policy Tracker Tool Car Parking Policy - Reading Policy/ Awareness Policy Tracker Tool Closed Circuit Television (CCTV) Non-Emergency Patient Transport Policy - Reading Policy/ Awareness Policy Tracker Tool Security and Access Policy Site Clearance/ Closure Policy Sustainability and Environmental Management Policy - Reading Policy/ Awareness - Reading Policy/ Awareness - Reading Policy/ Awareness 14 Policy Tracker Tool Policy Tracker Tool Policy Tracker Tool C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v

56 TOPIC/POLICY TRAINING STATUS e.g. Core - relevant for all staff (Blue) Role/Discipline/individual (Red) Departmentally Agreed (Yellow) DURATION OF TRAINING (if applicable) TRAINING DELIVERY FORMAT/ REGULARITY OF TRAINING (to be assessed on an annual basis during Personal Development & Planning process) Telecommunications - Reading Policy/ Awareness METHOD OF RECORDING AND REPORTING RE COMPLETION OF TRAINING/ INFORMATION GIVEN LearnPro NHS Tayside Training Database Local Reporting Systems Policy Tracker Tool eksf Policy Tracker Tool The Safe and Effective Use and Maintenance of Beds ½ hr session Face to face NHS Tayside Training Database Use of Mobile Communication Devices in Hospital and Healthcare Premises - Reading Policy/ Awareness Policy Tracker Tool Waste Management Policy Approx 40 mins LearnPro Module LearnPro Module 15 C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v

57 GROUP 5 RISK HEALTH & SAFETY POLICIES (INCLUDING FIRE SAFETY) TOPIC/POLICY Adverse Event Management Policy Aggression and Violence Management Policy Artificial Optical Radiation Safety TRAINING STATUS e.g. Core - relevant for all staff (Blue) Role/Discipline/individual (Red) Departmentally Agreed (Yellow) DURATION OF TRAINING (if applicable) TRAINING DELIVERY FORMAT/ REGULARITY OF TRAINING METHOD OF RECORDING AND REPORTING RE COMPLETION OF TRAINING/ INFORMATION GIVEN e.g. LearnPro NHS Tayside Training Database (to be assessed on Local Reporting Systems an annual basis Policy Tracker Tool during Personal eksf Development & Planning process) 2½ hours Face to face Local Reporting Systems 40 mins Bespoke Training LearnPro Module Face to face LearnPro - Face to Face Local Reporting Systems Control of Mercury - Face to face Local Reporting Systems Control of Substances Hazardous to Health Policy 3 hours Face to face Local Reporting Systems 16 C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v

58 TOPIC/POLICY Display Screen Equipment Policy Fire Safety Policy TRAINING STATUS e.g. Core - relevant for all staff (Blue) Role/Discipline/individual (Red) Departmentally Agreed (Yellow) DURATION OF TRAINING (if applicable) TRAINING DELIVERY FORMAT/ REGULARITY OF TRAINING (to be assessed on an annual basis during Personal Development & Planning process) 40 mins LearnPro Module 1 hour Face to face 40 mins LearnPro METHOD OF RECORDING AND REPORTING RE COMPLETION OF TRAINING/ INFORMATION GIVEN e.g. LearnPro NHS Tayside Training Database Local Reporting Systems Policy Tracker Tool eksf LearnPro Local Systems LearnPro Module First Aid Policy 2 days Face to face Local Reporting Systems General Risk Assessment Policy/DATIX Management of Health & Safety Policy Personal Protective Equipment ½ day awareness 2 days (Managers) 40 mins Fit Face Mask Training ½ day Face to face Face to face LearnPro Module Face to face Local Reporting Systems Local Reporting Systems LearnPro Local Reporting Systems Promote Safe Manual Handling Policy 40 mins Update ½ day LearnPro Module -Clinical -Non Clinical Face to face LearnPro NHS Tayside Training Database 17 C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v

59 TOPIC/POLICY Resilience Planning Storage and Use of Liquid Nitrogen TRAINING STATUS e.g. Core - relevant for all staff (Blue) Role/Discipline/individual (Red) Departmentally Agreed (Yellow) DURATION OF TRAINING (if applicable) TRAINING DELIVERY FORMAT/ REGULARITY OF TRAINING (to be assessed on an annual basis during Personal Development & Planning process) hours Face to face Local Reporting Systems METHOD OF RECORDING AND REPORTING RE COMPLETION OF TRAINING/ INFORMATION GIVEN e.g. LearnPro NHS Tayside Training Database Local Reporting Systems Policy Tracker Tool eksf 18 C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v

60 GROUP 6 HUMAN RESOURCES POLICIES TOPIC/POLICY Adverse Weather Policy TRAINING STATUS These policies are relevant for all staff/managers DURATION OF TRAINING (if applicable) TRAINING DELIVERY FORMAT/ REGULARITY OF TRAINING (to be assessed on an annual basis during Personal Development & Planning process) - Reading Policy/ Awareness METHOD OF RECORDING AND REPORTING RE COMPLETION OF TRAINING/INFORMATION GIVEN LearnPro NHS Tayside Training Database Local Reporting Systems Policy Tracker Tool eksf Policy Tracker Tool Alcohol, Drug and Other Substance Misuse Policy Breastfeeding and Returning to Work Policy Career Break Policy Carer Leave Policy Compassionate & Bereavement Leave Policy Critical Incident Employee Support Policy Dealing Positively with Stress at Work 3 hours Awareness sessions - Reading Policy/ Awareness - Reading Policy/ Awareness - Reading Policy/ Awareness - Reading Policy/ Awareness - Reading Policy/ Awareness - Reading Policy/ Awareness Face to face Policy Tracker Tool Policy Tracker Tool Policy Tracker Tool Policy Tracker Tool Policy Tracker Tool Policy Tracker Tool Local Reporting Systems 19 C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v

61 TOPIC/POLICY Embracing Equality Diversity & Human Rights TRAINING STATUS These policies are relevant for all staff/managers DURATION OF TRAINING (if applicable) TRAINING DELIVERY FORMAT/ REGULARITY OF TRAINING (to be assessed on an annual basis during Personal Development & Planning process) - Reading Policy/ Awareness METHOD OF RECORDING AND REPORTING RE COMPLETION OF TRAINING/INFORMATION GIVEN LearnPro NHS Tayside Training Database Local Reporting Systems Policy Tracker Tool eksf Policy Tracker Tool Employee Conduct Policy Employment of People with Disability Policy Facilities and Time Off Policy - Reading Policy/ Awareness Approx 40 LearnPro Module mins Equality & Diversity - Reading Policy/ Awareness Policy Tracker Tool LearnPro Policy Tracker Tool Gender-Based Violence Policy Approx 40 mins LearnPro Module Grievance Policy - Reading Policy/ Awareness LearnPro Policy Tracker Tool Induction & Orientation Policy Job Sharing Policy 1 day/ 2 days Face to Face/ LearnPro Modules - Reading Policy/ Awareness 20 LearnPro NHS Tayside Training Database Policy Tracker Tool C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v

62 TOPIC/POLICY Knowledge & Skills Framework/ Appraisal Process Lone Workers Policy TRAINING STATUS These policies are relevant for all staff/managers DURATION OF TRAINING (if applicable) 40 mins 1 hour workshop TRAINING DELIVERY FORMAT/ REGULARITY OF TRAINING (to be assessed on an annual basis during Personal Development & Planning process) LearnPro Module Direct Delivery - Reading Policy/ Awareness METHOD OF RECORDING AND REPORTING RE COMPLETION OF TRAINING/INFORMATION GIVEN LearnPro NHS Tayside Training Database Local Reporting Systems Policy Tracker Tool eksf LearnPro Local Reporting Systems eksf Policy Tracker Tool Long Service Award Management of Capability Policy Medical & Dental Employee Conduct Organisational Change and Protection Policy Parental and Shared Parental Leave Preventing & Dealing with Bullying & Harassment - Reading Policy/ Awareness - Reading Policy/ Awareness - Reading Policy/ Awareness - Reading Policy/ Awareness - Reading Policy/ Awareness - Reading Policy/ Awareness Policy Tracker Tool Policy Tracker Tool Policy Tracker Tool Policy Tracker Tool Policy Tracker Tool Policy Tracker Tool 21 C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v

63 TOPIC/POLICY Professional Registration Policy Promoting Attendance at Work Policy TRAINING STATUS These policies are relevant for all staff/managers DURATION OF TRAINING (if applicable) TRAINING DELIVERY FORMAT/ REGULARITY OF TRAINING (to be assessed on an annual basis during Personal Development & Planning process) - Reading Policy/ Awareness METHOD OF RECORDING AND REPORTING RE COMPLETION OF TRAINING/INFORMATION GIVEN LearnPro NHS Tayside Training Database Local Reporting Systems Policy Tracker Tool eksf Policy Tracker Tool - Face to Face Local Reporting Systems Recruitment and Selection Policy - Reading Policy/ Awareness Policy Tracker Tool Relocation Policy - Reading Policy/ Awareness Research Passport - Reading Policy/ Awareness Reserve Forces - Reading Policy/ Training and Awareness Mobilisation Retirement Policy ½ hour session on Pre- Retirement Face to face Secondment - Reading Policy/ Policy Awareness Skills Register - Reading Policy/ Awareness 22 Policy Tracker Tool Policy Tracker Tool Policy Tracker Tool NHS Tayside Training Database Policy Tracker Tool Policy Tracker Tool C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v

64 TOPIC/POLICY TRAINING STATUS These policies are relevant for all staff/managers DURATION OF TRAINING (if applicable) TRAINING DELIVERY FORMAT/ REGULARITY OF TRAINING (to be assessed on an annual basis during Personal Development & Planning process) Smoking Policy - Reading Policy/ Awareness Social Media - Reading Policy/ Awareness Special Leave - Reading Policy/ Policy Staff Travel and Accommodation Awareness - Reading Policy/ Awareness METHOD OF RECORDING AND REPORTING RE COMPLETION OF TRAINING/INFORMATION GIVEN LearnPro NHS Tayside Training Database Local Reporting Systems Policy Tracker Tool eksf Policy Tracker Tool Policy Tracker Tool Policy Tracker Tool Policy Tracker Tool Term Time Working Policy Uniform Workwear and Professional Appearance Policy Whistleblowing Policy Working at Home Policy - Reading Policy/ Awareness ½ hour session Face to face on Corporate Induction - Reading Policy/ Awareness - Reading Policy/ Awareness Policy Tracker Tool NHS Tayside Training Database Policy Tracker Tool Policy Tracker Tool 23 C:PM\Misc\Stat/Mand\Statutory and Mandatory Training Directory and Accountability Framework v

65 Appendix 1 Process to Ensure Robust Governance and Lines of Accountability for Statutory/Mandatory Training DIRECTORS GENERAL MANAGERS PROCESS IN PLACE TO SUPPORT IDENTIFICATION OF TRAINING NEED Senior Managers and Clinicians Appraisal System Annual PDR/PDP Identification of Statutory/ Mandatory training supported via use of Training Directory KSF/Senior Managers and Clinicians Appraisal System Annual PDR/PDP Identification of Statutory/ Mandatory training supported via use of Training Directory SYSTEM IN PLACE TO RECORD AND MONITOR ACTIVITY Senior Managers Clinicians Appraisal System LearnPro activity Reports for Directorates/IJBs eksf reports for Directorates/IJBs Clinical Governance Self Assessment Tool Senior Managers Appraisal FORA FOR GOVERNANCE/REPORTING ACCOUNTABILITY NHS Tayside Board Remuneration Committee Staff Governance Committee/ Area Partnership Forum Clinical & Care Governance Committee report Local Partnership Fora Directorate/IJBs Health & Safety Fora - Statutory/Mandatory training activity standing item reporting by Line Managers/General Managers SUPERVISORS/ LINE MANAGERS STAFF Annual PDR/PDP via KSF. Identification of Statutory/ Mandatory training supported via use of Training Directory Annual PDR/PDP via KSF. Identification of Statutory/ Mandatory training supported via use of Training Directory Regulation of Healthcare Support Workers (RHCSW) Induction Standards Competencies Workbooks Local recording systems Line Managers information via eksf system Line Managers information via databases LearnPro reporting via BOXI eksf system Policy Tracker Tool Training Database direct delivery training RHCSW Database erostering eess (in development) Performance Review Meetings Local team meetings stipulation to have a status update of Statutory/Mandatory training activity as a standing item on agendas Professional Registration Systems Continuous Professional Development (CPD) requirements Personal Accountability Regulation of Healthcare Support Workers (RHCSW) C:\PM\Misc\Statutory and Mandatory Training Directory and Accountability Framework v

66 Item 7.2 Please note any items relating to Staff Governance business are embargoed and should not be made public until after the meeting SGC/2017/01 Staff Governance Committee 14 March 2017 Safe & Improved Working Environment 1. Purpose To brief Committee Members on the creation of a Health & Safety Strategic Management Group, and share with Committee it s agreed terms of reference. 2. Situation and Background As part of the implementation of the Chief Executive's revised reporting structure, the Chief Operating Officer assumed responsibility for the management and oversight of health & safety on behalf of the Chief Executive. Having assumed responsibility, the Chief Operating Officer secured early support through appointing a interim professional Health & Safety consultant (Charter Member, Institute of Occupational Safety & Health qualified) to assist in scoping of key steps. An early action has been to refresh the existing Health & Safety reporting arrangements, including replacing the former Health & Safety Committee with a Health & Safety Strategic Management Group. Drawing membership from a range of professional specialists, this body is chaired by the Chief Operating Officer, supported by the Director of Human Resources & Organisational Development as Vice Chair, and includes line management and staff partner representatives. The terms of reference of that body are attached for information, and are intended to ensure a greater strategic oversight, reporting and direction to the range of issues that contribute to ensuring the health and safety of all those who work in or access our services. 3. Assessment Ensuring the effective management of health & safety is both a legal requirement and a key priority of the Board. Alongside establishing the Strategic Group, action is therefore being taken to appoint a Head of Health & Safety to fulfill the requirements of 'competent person' (i.e. with the necessary skills, knowledge and experience to manage and advise on Health and Safety) in line with the requirements of the 'Management of Health and Safety at Work Regulations 1999'. The role will play a key part in delivering an effective health & safety framework for NHS Tayside. Other steps being progressed as a priority include: Review of the Board's Health and Safety Strategy, with the previous strategy covering now expired By- directorate Risk Profiling to identify any key risk areas that may require specific and/or additional attention. Refresh of the Health & Safety Workbook - a management system introduced in 2010 Refresh of the Health & Safety web resources to ensure current information on key issues is available to all staff. 1

67 4. Recommendation Members are asked to note the creation of the Health & Safety Strategic Management Group, and priorities for future delivery. George Doherty Director of Human Resources & Organisational Development Lorna Wiggin Chief Operating Officer March

68 DRAFT NHS TAYSIDE HEALTH AND SAFETY MANAGEMENT GROUP These Terms of Reference have been prepared for initial consideration by the Health and Safety Group with a view to its submission to the care Governance Committee for formal adoption. 1. Purpose TERMS OF REFERENCE The purpose of the Health and Safety Management Group (HSMG) is to be responsible for the strategic overview of the health and safety issues and activities across NHS Tayside, provide assurance that health and safety risks are effectively managed on behalf of the organisation, and ensure the escalation of any areas of concern. The group will operate in a proactive way - reinforcing a positive safety culture and employee participation in the management of health and safety to ensure effective governance arrangements across all service areas. 2. Remit The HSMG will: Develop, implement, monitor and manage a strategic Health and Safety framework for NHS Tayside, to ensure NHS Tayside is compliant with statutory and legal requirements Where difficulties are highlighted in achieving the required levels of compliance the group will discuss this and make recommendations to mitigate the risk Assist the Chief Executive to deliver the Health and Safety Objectives for NHS Tayside Consider all areas of organisational risk or concern and review significant adverse events; where appropriate deliver instructions on the actions required to mitigate risks or make recommendations for improvement Establish short life working groups or commission audits on particular areas or practices as determined by risk, identified gaps, adverse events or HSE intervention Oversee and endorse Health and Safety Policies (new or revised) and any associated procedures and guidelines, submitting these for approval, through due process and adoption to the Audit Committee on behalf of the Board NHS TAYSIDE TERMS OF REFERENCE DOC VERSION 1 DECEMBER

69 DRAFT Consider and make recommendations on the allocation of the appropriate resources to fulfill the strategy aims and objectives Seek assurance that all statutory requirements are met by reviewing quarterly reports and themes from key stakeholders and other relevant management reports Consider new and revised legislation and best practice guidance, how it may impact the Board, and providing recommendations on any measures required to comply Respond to requests for consultation on new legislation and or guidance/best practice in relation to the management of health and safety affecting NHS Tayside Monitor, audit and review the effectiveness of organisational Health and Safety management arrangements, and ensure that all roles relating to the management of Health and Safety within NHS Tayside are understood and integrated into existing organisational management structures Receive and review regular updates on critical systems reports Receive bi-annual readiaton updates regarding radiation safety activity. To monitor and review the outcome of self assessment procedures required by external bodies (e.g. HSE, Internal Audit) authorised to inspect NHS Tayside H&S management processes. This includes developing plans, as appropriate to ensure that the organisation learns from national, local reviews and inspections and implements all necessary recommendations; To ensure that managers and staff are provided with effective H&S training, monitor the availability, take-up and effectiveness of health and safety training; Promote and develop a culture of understanding, co-operation, and delivery of the highest possible standards of health and safety at work is understood to be the responsibility of everyone working within NHS Tayside. Standing agenda items for every meeting: Quarterly Themed Reports Critical Systems Checklists H&S Risk Register Adverse Events and RIDDOR HSE visits/intervention NHS TAYSIDE TERMS OF REFERENCE DOC VERSION 1 DECEMBER

70 DRAFT Other H&S related concerns (Complaints and Claims) Health and Safety Audit H&S related policies H&S related training 3. Actions The HSMG will: Commit to the scheduled meetings Send a deputy when attendance cannot be met Read any relevant papers sent out ahead of the scheduled meetings Take information and actions back to their teams as necessary Fulfill within the agreed timescales any actions accepted from the meeting on behalf of the group 4. Membership The OHSMG will be made up of: Chief Operating Officer (Chair) or designate Director of HR & OD (Vice Chair) Head of Health and Safety Medical Director, Operational Unit Associate Director of Nursing General Manager x 2 (PRI site & 1 Other) (acting on behalf of the Operational Unit Directorates) Chief Officer x 3 (on behalf of the Health & Social Care Partnerships) Director of AHP Head of Property Property H&S Compliance Officer/Fire Safety Officer - rotating Associate Director of HR & OD Head of Occupational Health NHS TAYSIDE TERMS OF REFERENCE DOC VERSION 1 DECEMBER

71 DRAFT Head of Support Services Head of Radiation Physics Staff Side representatives as identified by the Area Partnership Forum will be invited to nominate safety representatives to attend 4.1 Ex Officio Members The following shall be ex-officio members of the Group Chief Executive Non Executive Chair of the Staff Governance Committee ( or Vice Chair as designated) 4.2 The HSMG may also seek attendance by relevant persons as required, including lead officers from Fire Safety, Moving & Handling, Violence and Aggression, Infection Control, and any other individuals and officers as deemed appropriate. 5. Quorum No business shall be transacted at a meeting unless the following quorum is met: Chairperson (or Vice Chair) Head of Health and Safety (or nominated deputy) Senior Management Representative x2 Partnership Representative Three other members of the committee excluding the above 6. Authority The HSMG is authorised by the Strategic Risk Management Group (SRMG). In order to fulfill its remit the HSMG may obtain whatever professional, technical or other advice it requires and may commission work to be delivered on its behalf. NHS TAYSIDE TERMS OF REFERENCE DOC VERSION 1 DECEMBER

72 DRAFT 7. Meeting Frequency The HSMG will meet monthly and in addition the Chairperson may call an extraordinary meeting should the situation require it. The meeting will have an agenda approved by the Chairperson ahead of each meeting and will be minuted. 8. Reporting Arrangements 8.1 The HSMG reports to the SRMC and through this group to the Board Staff Governance Committee. 8.2 The HSMG shall make recommendations to the SMRG, Staff Governance Committee, or determine any issues that need escalating to the Chief Executive to ensure appropriate action. 8.3 The HSMG should annually, and within three months of the start of the financial year, provide a work plan detailing the work to be taken forward by the Group to the SRMG. 8.4 Reports to be received by the HSMG: Health and Safety Quarterly Reports from each Directorate, Department, or Health & Social Care Partnership Reports from the Head of Health and Safety, or others as appropriate within the Health & Safety Advisory team Exception reporting from any department, function or external source 8.5 Minutes of the HSMG Meetings will be forwarded to the SMRG and cascaded down through departments by Managers 8.6 Annual Report The HSMG will produce and submit to the Staff Governance Committee an Annual report of the Board's safety management systems to measure effectiveness, performance, and provide assurance to the Board of compliance. 9. Amendments to the Terms of Reference NHS TAYSIDE TERMS OF REFERENCE DOC VERSION 1 DECEMBER

73 DRAFT Any amendments to the Terms of Reference will be made by the Group Chair and endorsed by the HSMG. NHS TAYSIDE TERMS OF REFERENCE DOC VERSION 1 DECEMBER

74 Item 8.1 Please note any items relating to Staff Governance business are embargoed and should not be made public until after the meeting SGC/2017/02 Staff Governance Committee 14 March 2017 MEDICAL WORKFORCE 1. STRATEGIC RISK This strategic risk states that As a result of national shortages of specific specialties and the impact of service redesign of the Medical Workforce, there is a risk of an insufficient supply of doctors in training and career grade doctors, including independent contractors, which may lead to a negative impact on patient care and sustainability of service provision. 2. CURRENT PERFORMANCE The following table reflects the change in inherent risk exposure with the current performance mapped alongside. Datix Ref Risk Title 95 Medical Workforce Lead Director Director of HR and OD Inherent Risk Exposure 25 (5x5) Very High June (4x5) Very High Sept (4x5) Very High Dec (4x5) Very High March (4x5) Very High The Staff Governance Committee is asked to note that there has been no change in relation to the Current Risk Exposure Rating, notwithstanding the steps described in the Assurance Section below. A new three month risk review date has been added.. 1

75 3. ASSURANCE The Committee is asked to note the following steps being taken to implement mitigate the risk: New Deal monitoring for each rota twice per year, with support to Lead Clinicians, managers and doctors in training in relation to the understanding, management and individual responsibilities to comply with the regulations, eg monitoring guidelines for each rota for each Trainee, pre monitoring talks to all trainees, non compliance rotas reported to Rotamaster and an identified consultant. Local Workforce Plans developed by General Managers and Lead Clinicians to redesign models of service delivery to reduce the reliance on doctors in training Public consultation in relation to the Shaping Surgical Services and the Review of Mental Health Services provision is underway. Preparation for the development of the Corporate Workforce Plan and Projections 2017/18 to inform Scottish Government in relation to training numbers etc, is underway. Intelligence gained through and contribution to the influencing power of the North of Scotland Medical Workforce Planning Group. Adjustment of consultant on-call rota to ensure adequate senior clinician decision making is available when the more senior ST grades are unfilled Employing Specialty Doctors and Locums with and without training numbers to minimise gaps in service delivery, as well as Agency Doctors Piloting the introduction of Physicians Associates to guage impact on rostering compliance. Engagement in social media network advertising to target the passive market. Introduction of advanced practitioner roles to support Primary Care 4. CONCLUSION Work is continuing to improve performance to mitigate risk, in relation to the assurance above. 5. FURTHER ACTION As result of the continued and projected national shortage of many of the Specialties within the National Health Service in the UK, it is anticipated that this risk will remain as a strategic risk for the foreseeable future. The following actions in addition to the above will be focussed upon and will feature in the Strategic Risk Report at the next meeting of the Staff Governance Committee It has been announced that there is to be a National Workforce Plan for Scotland. When more information is available, its development and impact will be contributed to, reported and acted upon. The balance of patient safety and budgetary control responsibility of the Directors continues. Additional operational risks to be considered and articulated to support the mitigation of the strategic risk as identified. 6. REPORT SIGN OFF Mr G Doherty Mrs J Mudie Ms L McLay Director of HR and OD Associate Director of HR and OD, Chief Executive Governance 24 February

76 Item 8.2 Please note any items relating to Staff Governance business are embargoed and should not be made public until after the meeting SGC/2017/03 Staff Governance Committee 14 March 2017 WORKFORCE OPTIMISATION 1. STRATEGIC RISK The Corporate Workforce Plan has been reporting challenges in relation to the supply and deployment of staff, in particular in relation to certain professional groups eg nursing and small occupational groups such as Sonography. There has been an increasing reliance on supplementary staffing such as Agency, which is turn has resulted in increased costs for NHS Tayside. NHS Tayside has always promoted patient safety and good quality care and therefore the strategic risk in relation to the efficient and effective deployment of the workforce could lead to a negative impact on the quality of patient care, service delivery and financial balance. 2. CURRENT PERFORMANCE Recent and current performance against this risk is highlighted in the table below: Datix Ref Risk Title 58 Workforce Optimisation Lead Director Director of HR and OD Inherent Risk Exposure 20 (5x4) Very High June (4x3) High September (4x4) High December (4x5) Very High March (4x5) Very High. The Staff Governance Committee is asked to note that there has been no change in relation to the Current Risk Exposure Rating, notwithstanding the steps described in the Assurance Section below. A new three month risk review date has been added. In addition the Director of HR and OD, the Associate Director of HR and OD and the Risk Manager of the Clinical Governance and Risk Team will meet to carry out their annual review of the Strategic Risks to consider their inter relationship with other Strategic Risks in March

77 3. ASSURANCE The Committee is asked to note the following steps being taken to implement mitigate the risk: Directors and Chief Officers plan for design of future service delivery taking into account Health and Social Care Partnerships, the opportunities provided by succession planning information and a national/regional Clinical Strategy and the Clinical Strategy of NHS Tayside. Local Workforce Plans are live documents that are reported upon and discussed at the Local Partnership Fora. The Local Workforce Plans inform the Staffing Projections for NHS Tayside and the Corporate Workforce Plan. Directorate Performance and Scrutiny Groups lead by the Chief Operating Officer and the Chief Officers of the IJB Partnerships, which include operational staff management and staff governance issues. The governance of the NHS Tayside Redeployment Register and procedure is implemented in partnership with staffside. Workforce Information is provided to support line managers plan and manage the workforce. Finance reports identifying staffing costs are shared in management meetings, Area Partnership Forum and NHS Tayside Board Maintenance of an active Nurse Bank with appropriately skilled Bank Nurses Providing regular workforce information reports to Scottish Government to inform national planning, particularly in respect of national training numbers. Implementation of the Attraction and Recruitment Strategy for NHS Tayside Analysis of the results from the On-line Exit Questionnaire Survey along with learning from individual interviews. Management of Attendance at Work and staff wellbeing. Prospective recruitment to minimise supplementary costs as directed by appropriate budget holder or Executive Lead. Effective management of fixed term contracts. Review of shift lengths and patterns for nursing staff. 4. CONCLUSION Work is continuing, to maintain performance and improve where possible, in relation to the actions above. 5. FURTHER ACTION As result of the continued and projected national shortage of many of the job families within the National Health Service in the UK, it is anticipated that this risk will remain as a strategic risk for the foreseeable future. The following actions were highlighted in the previous report to the Staff Governance Committee and progress is as follows A consultation document in relation to a National Workforce Plan for Scotland is currently being considered by NHS Boards, Local Authorities and Partnership Bodies. Its outcome will be reported to the Staff Governance Committee when available. The roll out of e Rostering continues across NHS Tayside, as does the budgetary control responsibility of the Directors for staffing numbers and deployment. A review of the management and administrative structures of the Corporate function of 2

78 NHS Tayside is underway. This will rationalise the provision of managerial and administrative services and provide assurance around the effective deployment of staff. In addition to the above will be focussed upon and will feature in the Strategic Risk Report at the next meeting of the Staff Governance Committee Contact is being made with nurses and midwives who left NHS Tayside in 2016 with a view to offering support if they wish to return to nursing/midwifery in NHS Tayside. The Nurse Director wishes to establish a nursing and midwifery pool in addition to the Nurse Bank. 6. REPORT SIGN OFF Mr G Doherty Mrs J Mudie Ms L McLay Director of HR and OD Associate Director of HR and OD, Chief Executive Governance 24 February

79 Please note any items relating to Staff Governance business are embargoed and should not be made public until after the meeting Item 8.3 SGC/2017/04 Staff Governance Committee 14 March 2017 ASSURANCE REPORT ON NURSING AND MIDWIFERY WORKFORCE RISK 1. STRATEGIC RISK The Board Assurance Framework Strategic Risk Profile and individual risk reports from DATIX aims to identify the Strategic Risks that could impact on the delivery of NHS Tayside s objectives. The risk to which this report relates is the Nursing & Midwifery Workforce Risk with the principle objective being to deliver on the priority areas in our Clinical Strategy including achieving HEAT targets and standards and improve patient experience of our services. The Assurance Framework describes the corporate risk in relation to the potential failure to recruit and retain sufficient numbers of registered nurses and midwives which would result in a failure to maintain safe and effective nursing and midwifery staffing levels impacting on patient and staff experience. Compounding this risk was the introduction of Nursing and Midwifery Council (NMC) revalidation for all registered nurses and midwives from April NMC revalidation is mandatory and registration is at risk without active participation. If nurses and midwives fail to maintain their registration this could impact on the organisation s ability to maintain an adequate NMC registered workforce. 2. CURRENT PERFORMANCE Current performance against this risk is highlighted in the table below:- Datix Risk Title Reference 280 Nursing and Midwifery Workforce Lead Director Nurse Director Inherent Risk Exposure 20 (5x4) Very High Date of Last Update February 2017 The rationale for the current score (20 (5 x 4) Very High) reflects the consequence and likelihood which are automatically generated within the Datix system. 3. ASSURANCE The current controls in place to mitigate this risk are set out in the attached DATIX report. These principally reflect the current mechanisms and actions that are being taken by the Nursing & Midwifery Directorate and Human Resources & Organisational Development Directorate. Nursing & Midwifery Workforce is a key component of the Transformation Programmes Workforce and Care Assurance Programme and is an agenda item at both strategic and operational performance fora. This offers a level of assurance and demonstrates 1

80 collaborative working coupled with monitoring and surveillance for the management of this strategic risk. 4. REPORT DETAIL Nurses and Midwives play a crucial role in the delivery of safe and effective, person centred care and represent the largest staff group employed within the NHS. It is essential that there is a systematic and consistent approach to nursing & midwifery workforce planning across the organisation and a proactive approach to recruitment and retention. As a result of a national shortage and local workforce demographics (ageing workforce), there is a risk that we will be unable to recruit and retain sufficient numbers of registered nurses and midwives which will result in a failure to maintain safe and effective nursing and midwifery staffing levels. The attached DATIX report details the actions being progressed to mitigate the risk. Current performance highlights that the Nursing & Midwifery Workforce remains very high risk despite the progress with a number of the mitigating actions. Supplementary staffing, staff turnover and predicted absence are now monitored weekly with Heads of Nursing. 5. CONCLUSION The Nursing & Midwifery Directorate will continue to work collaboratively to with both local Universities to promote NHS Tayside as the employer of choice. Both Nursing & Midwifery Directorate and Human Resources & Organisational Development Directorate are working collaboratively to understand the current recruitment and retention challenges and implement mitigating actions to reduce the level of risk. 6. REPORT SIGN OFF Mrs E McKenna Associate Nurse Director Mrs G Costello Nurse Director 1 March

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89 Item 9.1 Please note any items relating to Staff Governance business are embargoed and should not be made public until after the SGC/2017/05 Staff Governance Committee 14 March 2017 CORPORATE WORKFORCE DASHBOARD STAFF GOVERNANCE COMMITTEE AND THE FINANCES AND RESOURCES COMMITTEE 1. SITUATION AND BACKGROUND With reference to the Internal Audit Annual Report 2015/2016 on the Staff Governance Committee the Director of HR and OD and the Director of Finance have developed a joint dataset that would be considered by both Staff Governance Committee and the Finance and Resources Committee. A dashboard style report has been designed. In order to maximise the time to populate the dashboard with information that is as live as possible, the dashboard will be presented onscreen at the meeting, but an early copy will be forwarded to the Staff Governance Committee members by Friday 10 March 2017 for familiarisation. 2. ASSESSMENT The sources of data are predominantly NHS Tayside payroll, ISD and NHS Tayside s Workforce Plan and the dashboard is populated by members of the HR and OD Directorate and the Finance Directorate. The dashboard identifies a number of metrics that can inform understanding and decision making by both the Staff Governance and Finance and Resources Committee. The Staff Governance Committee is asked is view in relation to: The relevance of the metrics The clarity of the information The presentation of the information The timescales for reporting eg in order to provide as current information as possible, different reporting streams will result in different timespans. In addition, in due course, providing an Annual Report that compares NHS Tayside s data with other Boards where such data is available through ISD In due course, providing information in relation to NHS Scotland average, where such information is available through ISD. 3. RECOMMENDATIONS The Committee members are asked for feedback in relation to the above points in order to inform further refinement of the dashboard. 1

90 4. REPORT SIGN OFF Jennifer Mudie Ian Sturrock George Doherty Associate Director of HR & OD, HR Lead Information Director of HR and OD Governance Services NHS Tayside NHS Tayside NHS Tayside 14 March

91 APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR Corporate Workforce Dashboard - Feb 17 data source - epayroll/efinancials/hr recording systems WTE Contracted Hours 16/17 - Feb 17 Cost Actual Hours Paid 16/17 in 000's Cost Supplementary Spend 16/17 in 000's Total Cost Paybill 16/17 in 000's , , , / / / / / / / / / / / / , , , , , , , , ,584.8 WTE Trend 16/17 Hours Paid Trend 16/17 Supplementary Cost Trend 16/17 Total Paybill Cost Trend 16/17 Apl Feb Projections ,701 Apl 16 31,165 Jan 17 1, ,587.8 Apl 16 Jan 17 41,621.1 Apl 16 44,517.5 Jan % 8.39% 2013/ / / / / / % 4.81% 4.91% 7.88% 9.19% 9.56% 4.53% Apl 16 Absence Trend 16/17 Turnover Trend 16/17 ian sturrock - information services Absence - Jan 17 Turnover - Feb % Jan17 Standard 4% Apl % Feb % NHS TAYSIDE METRICS as at February 2017 paybill Family DISCIPLINARY GRIEVANCE DIGNITY DISMISSAL VACANCIES RATE% NHS TAYSIDE % Administrative Services 14 <5 <5 < % Allied Health Profession % Dental Support % Healthcare Sciences < % Medical And Dental <5 <5 < % Medical Support % Nursing/Midwifery % Other Therapeutic < % Support Services 21 <5 < % Skill Mix by Family AFC Band 1-4 AFC Band 5-7 AFC Band 8+ Grand Total NHS Tayside Administrative Services Allied Health Profession Dental Support Healthcare Sciences Medical And Dental Medical Support Nursing/Midwifery Other Therapeutic Support Services Female Gender Age Profile Male PRR eksf PDP 40.46% 38.79% NHS TAYSIDE Headcount WTE

92 WORKFORCE INFORMATION REPORT December Q3 INDEX 1 Historical Trend WTE NHS Tayside - All Staff Nursing & Midwifery Administrative Services 2 Current Staffing Numbers Whole Time Equivalent Part Time/Full Time Ratio Contract Status Ratio 3 Grade Mix by Gender 4 Age Profile 5 Turnover 6 Absence 7 Formal Processes Grievance Discipline Bullying & Harassment in the Workplace Attendance Dismissals

93 WTE Dec 11 to Dec 16 - NHS Tayside Dec-11, Mar-12 Mar-13 Dec-13 Mar-14 Dec-14 Mar-15 Dec-15 Mar-16 Dec-16, WTE Trend SG Projections 16/ Dec NHS Tayside Dec-11 Mar-12 Dec-12 Mar-13 Dec-13 Mar-14 Dec-14 Mar-15 Dec-15 Mar-16 Dec-16 Administrative Services Allied Health Profession Healthcare Sciences Medical And Dental Medical And Dental Support Nursing/Midwifery Other Therapeutic Support Services Grand Total

94 WTE Dec 11 to Dec 16 - Nursing & Midwifery Dec-11, Mar-12 Dec-12 Mar-13 Dec-13 Mar-14 Dec-14 Mar-15 Dec-15 Mar-16 WTE Trend SG Projections 16/ Dec-16, Nursing & Midwifery Dec-11 Mar-12 Dec-12 Mar-13 Dec-13 Mar-14 Dec-14 Mar-15 Dec-15 Mar-16 Dec

95 WTE Dec 11 to Dec 16 - Administrative Services Dec-11, Mar-12 Dec-16, Dec-12 Mar-13 Dec-13 Mar-14 Dec-14 Mar-15 Dec-15 Mar-16 WTE Trend SG Projections 16/ Administrative Services Dec-11 Mar-12 Dec-12 Mar-13 Dec-13 Mar-14 Dec-14 Mar-15 Dec-15 Mar-16 Dec-16 Central Functions Clinical Support Senior Managers Grand Total

96 NHS Tayside - Whole Time Equivalent/Headcount Appendix 2a Source Data Scottish Standard Payroll System (SSPS) Projection Dec-2016 Date Dec Author Ian Sturrock Status v Proj this mth WTE Current Status Projection WTE at Apr Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 WTE/HEADCOUNT By Staff Type 1st April 2016 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Staff Type WTE Headcount WTE Headcount WTE Headcount WTE Headcount WTE Headcount Administrative Services* Allied Health Profession Dental Support Healthcare Sciences Medical And Dental Medical Support Nursing/Midwifery Other Therapeutic Support Services Total NHS Tayside * includes Senior Management nb: Headcount excludes Bank Staff WTE/HEADCOUNT By Group 1st April 2016 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Staff Type WTE Headcount WTE Headcount WTE Headcount WTE Headcount WTE Headcount Access Directorate IJB - Angus Corporate & Board IJB - Dundee Operations Directorate Medicine Directorate IJB - Perth Specialist Service Directorate Surgery & Theatres Directorate Mental Health Directorate Tayside Community Directorate Total NHS Tayside

97 Current Staff Ratios: Headcount Appendix 2b Part Time/ Full Time Ratio Dec-13 Dec Part Time Full Time Part Time Full Time Part Time % Part Time % Full Time % Full Time % Contract Status Ratio Dec-13 Dec Permanent Permanent Fixed Term Secondment Fixed Term Secondment Fixed Term Fixed Term Permanent % Permanent % Fixed Term Secondment % Fixed Term Secondment % Fixed Term % Fixed Term %

98 Grade Mix By Gender - Headcount Appendix 3 Band Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male AFC Band % 50.00% % 20.26% % 28.45% % 25.57% AFC Band % 23.30% % 24.29% % 21.96% % 21.31% AFC Band % 22.57% % 22.43% % 22.15% % 21.93% AFC Band % 15.57% % 15.72% % 15.55% % 16.91% AFC Band % 11.66% % 11.17% % 11.40% % 11.17% AFC Band % 14.31% % 14.95% % 14.43% % 15.02% AFC Band % 16.71% % 16.96% % 18.26% % 18.65% AFC Band % 23.57% % 24.84% % 24.75% % 24.62% Medical And Dental % 50.34% % 48.61% % 48.11% % 50.12% Senior Manager % 31.67% % 34.33% % 40.28% % 41.03% T Scales % 15.38% % 14.29% % 15.00% Grand Total % 20.69% % 20.56% % 20.59% % 20.64% Staff Type December-2016 December-2015 December-2014 December-2013 December-2016 December-2015 December-2014 December-2013 Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Administrative Services % 12.87% % 13.32% % 13.63% % 13.49% Allied Health Profession % 12.05% % 11.85% % 12.91% % 12.82% Dental Support % 13.24% % 14.08% % 13.81% % 14.08% Healthcare Sciences % 33.22% % 36.00% % 37.01% % 37.48% Medical And Dental % 50.34% % 48.61% % 48.11% % 50.12% Medical Support % 38.89% % 50.00% Nursing/Midwifery % 11.00% % 11.02% % 11.06% % 11.11% Other Therapeutic % 20.43% % 21.24% % 20.13% % 20.22% Support Services % 45.47% % 44.39% % 43.96% % 42.46% Grand Total % 20.69% % 20.56% % 20.59% % 20.64%

99 NHS Tayside Age Profile - Headcount as at December 2016 Appendix 4 Job Family and over NHS Tayside % Administrative Services % Allied Health Profession % Dental Support % Healthcare Sciences % Medical And Dental % Medical Support % Nursing/Midwifery % Other Therapeutic % Support Services % Age Profile NHS Tayside Dec Dec-13 Dec-16 Dec Administrative Services Allied Health Profession Healthcare Sciences Medical And Dental Dental Support Nursing/Midwifery Other Therapeutic Support Services

100 NHS Tayside Turnover Appendix 5a Family Annual % Annual % Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Administrative Services 8.34% 8.01% 7.33% 7.22% 7.22% 8.89% 9.58% 8.07% 8.07% Allied Health Profession 11.88% 13.06% 10.96% 10.40% 10.40% 7.95% 10.21% 9.87% 9.87% Dental Support 5.85% 4.83% 5.83% 7.00% 7.00% 22.34% 16.33% 11.11% 11.11% Healthcare Sciences 13.67% 13.45% 12.06% 11.09% 11.09% 10.87% 9.89% 8.72% 8.72% Medical Non Training 11.19% 14.42% 11.81% 11.51% 11.51% 10.85% 10.67% 10.41% 10.41% Medical Support 28.57% 14.29% 7.41% 7.41% Nursing/Midwifery 8.86% 10.37% 10.12% 9.68% 9.68% 11.30% 10.41% 9.36% 9.36% Other Therapeutic 8.39% 12.08% 10.45% 9.51% 9.51% 8.80% 11.58% 9.69% 9.69% Support Services 13.95% 13.02% 11.77% 10.87% 10.87% 8.04% 8.18% 7.11% 7.11% NHS Tayside 9.93% 10.82% 10.01% 9.56% 9.56% 10.22% 10.09% 8.95% 8.95% 12.00% 10.00% NHS Tayside 10.82% 10.22% 10.09% 9.93% 10.01% 8.95% 9.56% NHS Tayside Adj Status Q1 9.93% 10.22% 0.30% an increase Q % 10.09% -0.73% a decrease 8.00% Q % 8.95% -1.06% a decrease 6.00% 4.00% Q4 9.56% 2.00% 0.00% Q1 Q2 Q3 Q % Administrative Services Administrative Services Adj Status Q1 8.34% 8.89% 0.54% an increase 10.00% 8.00% 8.34% 8.89% 9.58% 8.01% 8.07% 7.33% 7.22% Q2 8.01% 9.58% 1.58% an increase Q3 7.33% 8.07% 0.74% an increase 6.00% 4.00% Q4 7.22% 2.00% 0.00% Q1 Q2 Q3 Q % 12.00% 10.00% 8.00% 6.00% 11.88% Allied Health Professions 13.06% 10.96% 10.21% 10.40% 9.87% 7.95% Allied Health Profession Adj Status Q % 7.95% -3.93% a decrease Q % 10.21% -2.86% a decrease Q % 9.87% -1.10% a decrease Q % 4.00% 2.00% 0.00% Q1 Q2 Q3 Q4

101 NHS Tayside Turnover Appendix 5b Family Annual % Annual % Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Administrative Services 8.34% 8.01% 7.33% 7.22% 7.22% 8.89% 9.58% 8.07% 8.07% Allied Health Profession 11.88% 13.06% 10.96% 10.40% 10.40% 7.95% 10.21% 9.87% 9.87% Dental Support 5.85% 4.83% 5.83% 7.00% 7.00% 22.34% 16.33% 11.11% 11.11% Healthcare Sciences 13.67% 13.45% 12.06% 11.09% 11.09% 10.87% 9.89% 8.72% 8.72% Medical Non Training 11.19% 14.42% 11.81% 11.51% 11.51% 10.85% 10.67% 10.41% 10.41% Medical Support 28.57% 14.29% 7.41% 7.41% Nursing/Midwifery 8.86% 10.37% 10.12% 9.68% 9.68% 11.30% 10.41% 9.36% 9.36% Other Therapeutic 8.39% 12.08% 10.45% 9.51% 9.51% 8.80% 11.58% 9.69% 9.69% Support Services 13.95% 13.02% 11.77% 10.87% 10.87% 8.04% 8.18% 7.11% 7.11% NHS Tayside 9.93% 10.82% 10.01% 9.56% 9.56% 10.22% 10.09% 8.95% 8.95% 25.00% 22.34% Dental Support Dental Support Adj Status Q1 5.85% 22.34% 16.48% an increase 20.00% 15.00% 10.00% 5.00% 5.85% 4.83% 16.33% 5.83% 11.11% 7.00% Q2 4.83% 16.33% 11.50% an increase Q3 5.83% 11.11% 5.29% an increase Q4 7.00% 0.00% Q1 Q2 Q3 Q % 14.00% 12.00% 10.00% 8.00% 6.00% Healthcare Sciences 13.67% 13.45% 12.06% 10.87% 11.09% 9.89% 8.72% Healthcare Sciences Adj Status Q % 10.87% -2.80% a decrease Q % 9.89% -3.56% a decrease Q % 8.72% -3.34% a decrease Q % 4.00% 2.00% 0.00% Q1 Q2 Q3 Q % 14.00% 12.00% 10.00% 8.00% 6.00% Medical Non Training 14.42% 11.81% 11.19% 11.51% 10.85% 10.67% 10.41% Medical Non Training Adj Status Q % 10.85% -0.33% a decrease Q % 10.67% -3.76% a decrease Q % 10.41% -1.40% a decrease Q % 4.00% 2.00% 0.00% Q1 Q2 Q3 Q4

102 NHS Tayside Turnover Appendix 5c Family Annual % Annual % Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Administrative Services 8.34% 8.01% 7.33% 7.22% 7.22% 8.89% 9.58% 8.07% 8.07% Allied Health Profession 11.88% 13.06% 10.96% 10.40% 10.40% 7.95% 10.21% 9.87% 9.87% Dental Support 5.85% 4.83% 5.83% 7.00% 7.00% 22.34% 16.33% 11.11% 11.11% Healthcare Sciences 13.67% 13.45% 12.06% 11.09% 11.09% 10.87% 9.89% 8.72% 8.72% Medical Non Training 11.19% 14.42% 11.81% 11.51% 11.51% 10.85% 10.67% 10.41% 10.41% Medical Support 28.57% 14.29% 7.41% 7.41% Nursing/Midwifery 8.86% 10.37% 10.12% 9.68% 9.68% 11.30% 10.41% 9.36% 9.36% Other Therapeutic 8.39% 12.08% 10.45% 9.51% 9.51% 8.80% 11.58% 9.69% 9.69% Support Services 13.95% 13.02% 11.77% 10.87% 10.87% 8.04% 8.18% 7.11% 7.11% NHS Tayside 9.93% 10.82% 10.01% 9.56% 9.56% 10.22% 10.09% 8.95% 8.95% 12.00% 10.00% 8.86% 11.30% Nursing & Midwifery 10.37% 10.41% 10.12% 9.68% 9.36% Nursing/Midwifery Adj Status Q1 8.86% 11.30% 2.44% an increase Q % 10.41% 0.03% an increase 8.00% Q % 9.36% -0.77% a decrease 6.00% 4.00% Q4 9.68% 2.00% 0.00% Q1 Q2 Q3 Q % 12.00% 10.00% 8.00% 6.00% 8.39% 8.80% Other Therapeutic 12.08% 11.58% 10.45% 9.69% 9.51% Other Therapeutic Adj Status Q1 8.39% 8.80% 0.41% an increase Q % 11.58% -0.51% a decrease Q % 9.69% -0.75% a decrease Q4 9.51% 4.00% 2.00% 0.00% Q1 Q2 Q3 Q % 14.00% 12.00% 10.00% 8.00% 6.00% Support Services 13.95% 13.02% 11.77% 10.87% 8.04% 8.18% 7.11% Support Services Adj Status Q % 8.04% -5.90% a decrease Q % 8.18% -4.85% a decrease Q % 7.11% -4.66% a decrease Q % 4.00% 2.00% 0.00% Q1 Q2 Q3 Q4

103 Absence Trend Analysis NHS Tayside Appendix 6 Source Data Scottish Standard Payroll System (SSPS) Standard Dec-2016 Date Dec % 4.96% Author Ian Sturrock Overall Absence Trends Perf v Target this mth 0.96% Performance %Standard Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar Long & Short Term Trends Short Term Long Term 1.00 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Statistics from Data Table Quarter 1 Quarter 2 Quarter 3 Quarter 4 Annual % 4.71% 4.64% 4.70% 4.78% 5.02% 5.22% 4.91% Trend -0.18% -0.07% -0.24% Previous Mth v Current Mth Nov-16 Dec-16 Overall 4.79% 4.96% Increase by 0.17% Long 2.04% 2.29% Increase by 0.25% Short 2.75% 2.67% Decrease by -0.08% Last Year v Current Mth Dec-15 Dec-16 Overall 5.26% 4.96% Decrease by -0.30% Long 2.82% 2.29% Decrease by -0.53% Short 2.43% 2.67% Increase by 0.23%

104 NHS TAYSIDE Formal Processes GROUP Headcount Administrative Services Cumulative Grievance Allied Health Profession Healthcare Sciences Medical And Dental Dental Support Medical Support Nursing/Midwifery Other Therapeutic Appendix 7a NHS Tayside Total Grievance <5 <5 <5 8 Access Directorate 1503 IJB - Angus 842 Corporate & Board 911 <5 <5 IJB - Dundee 1402 Operations Directorate 1838 <5 <5 Mental Health Directorate 251 Medicine Directorate 2420 <5 <5 IJB - Perth 1580 Specialist Service Directorate 1058 Surgery & Theatres Directorate 1653 <5 <5 Tayside Community Directorate 364 Cumulative Discipline GROUP Headcount Administrative Services Allied Health Profession Healthcare Sciences Medical And Dental Dental Support Medical Support Nursing/Midwifery Other Therapeutic Support Services Total NHS Tayside Total Discipline 11 <5 <5 21 < Access Directorate 1503 <5 <5 <5 <5 <5 IJB - Angus 842 Corporate & Board 911 <5 <5 <5 IJB - Dundee 1402 <5 <5 <5 Operations Directorate 1838 < Mental Health Directorate 251 <5 <5 Medicine Directorate 2420 <5 6 9 IJB - Perth 1580 <5 6 8 Specialist Service Directorate 1058 <5 <5 <5 Surgery & Theatres Directorate 1653 <5 <5 5 Tayside Community Directorate 364 <5 <5 Cumulative Bullying & Harassment in the Workplace GROUP Headcount Administrative Services Allied Health Profession Healthcare Sciences Medical And Dental Dental Support Medical Support Nursing/Midwifery Other Therapeutic Support Services Total NHS Tayside Total B&H in Workplace <5 < Access Directorate 1503 IJB - Angus 842 <5 <5 Corporate & Board 911 <5 <5 <5 IJB - Dundee 1402 <5 <5 Operations Directorate 1838 Mental Health Directorate 251 Medicine Directorate 2420 <5 <5 <5 IJB - Perth 1580 <5 <5 Specialist Service Directorate 1058 Surgery & Theatres Directorate 1653 <5 <5 Tayside Community Directorate 364 Cumulative Attendance Dismissals (please see note at Appendix 7b) GROUP Headcount Administrative Services Allied Health Profession Healthcare Sciences Medical And Dental Dental Support Medical Support Nursing/Midwifery Other Therapeutic Support Services Total NHS Tayside Total Attendance Dismissals <5 < Access Directorate 1503 <5 <5 <5 IJB - Angus 842 <5 <5 Corporate & Board 911 IJB - Dundee 1402 <5 <5 Operations Directorate Mental Health Directorate 251 Medicine Directorate 2420 <5 <5 IJB - Perth Specialist Service Directorate 1058 <5 <5 Surgery & Theatres Directorate 1653 <5 5 6 Tayside Community Directorate 364 <5 <5 Support Services Total

105 NHS TAYSIDE Formal Processes : Trend Analysis Appendix 7b Grievance Discipline Quarter 1 Quarter 2 Quarter 3 Quarter 4 Total Quarter 1 Quarter 2 Quarter 3 Quarter 4 Total Group NHS Tayside <5 <5 7 <5 <5 < Access Directorate <5 <5 <5 <5 <5 <5 IJB - Angus <5 <5 <5 <5 Corporate & Board <5 <5 <5 <5 <5 <5 <5 IJB - Dundee <5 <5 <5 <5 <5 <5 <5 <5 <5 Operations Directorate <5 <5 <5 <5 <5 <5 9 <5 7 <5 5 < Mental Health Directorate <5 <5 <5 <5 <5 9 <5 Medicine Directorate <5 <5 <5 <5 <5 <5 <5 <5 <5 <5 <5 7 8 IJB - Perth <5 <5 <5 <5 <5 <5 8 Specialist Service Directorate 5 5 <5 <5 <5 <5 <5 <5 <5 Surgery & Theatres Directorate <5 <5 <5 <5 <5 <5 <5 <5 <5 7 5 Tayside Community Directorate <5 <5 <5 <5 <5 Bullying & Harassment in the Workplace Attendance Dismissals Quarter 1 Quarter 2 Quarter 3 Quarter 4 Total Quarter 1 Quarter 2 Quarter 3 Quarter 4 NotKnown Total Group NHS Tayside < < < Access Directorate <5 <5 <5 <5 <5 <5 <5 IJB - Angus <5 <5 <5 <5 <5 <5 <5 <5 <5 Corporate & Board <5 <5 <5 <5 <5 IJB - Dundee <5 <5 <5 <5 <5 <5 <5 <5 <5 5 <5 Operations Directorate <5 <5 5 6 <5 <5 <5 5 7 < Mental Health Directorate <5 <5 <5 <5 <5 <5 Medicine Directorate <5 <5 <5 <5 <5 <5 <5 <5 <5 <5 <5 <5 <5 IJB - Perth <5 <5 <5 <5 <5 <5 7 Specialist Service Directorate 5 5 <5 <5 <5 <5 <5 7 <5 Surgery & Theatres Directorate <5 <5 <5 <5 <5 <5 <5 <5 <5 7 6 Tayside Community Directorate <5 <5 Note: Grievances: Please note that the numbers contained within this section reflect those cases that are not resolved at the informal stage of the Grievance Procedure and progress to the 1st Formal Stage. Each case should only be referred to once, unless a different procedure is subsequently used eg a grievance lodged by employee A results in a conduct case in relation to employee B. General note: Please note these numbers reflect the number of cases that are raised in that quarter and is not a measure of the volume of meetings or levels/appeals for each case.

106 Please note any items relating to Staff Governance business are embargoed and should not be made public until after the meeting Item SGC/2017/07 Staff Governance Committee March 2017 Promoting Attendance: Quarter Report 1. SITUATION AND BACKGROUND This report details performance in relation to promoting attendance/sickness absence for Quarter 3, October 2016 to December ASSESSMENT In common with other Boards across NHS Scotland, NHS Tayside is working to achieve a sickness absence rate of 4.0% absence, calculated on the basis of lost hours. 2.1 Highlight analysis The rate of sickness absence for NHS Tayside for the third quarter period 2016/17 was 4.81%. This represents an annual decrease of 0.24% on the similar period for 2015/16. (Source: NHS Tayside Information Report December 2016) NHS Tayside 3 rd Quarter performance demonstrated a slight increase of 0.14% on the previous quarter, i.e. Quarter 2 in the 2016/17 figures. Table 1 details changes in absence percentages from the third quarter of 2015/16 through to the second quarter of 2016/17 (Source: NHS Tayside Information Report September 2016) Table 1 Directorate/CHP 2015/16 Q4 2016/17 Q1 2016/17 Q2 2016/17 Q3 +/- (on previous quarter Dundee Partnership Access Operations Mental Health Perth & Kinross Partnership Surgery & Theatres Corporate Medicine Tayside Communities Specialist Angus Partnership

107 The Staff Governance Committee has requested a trend analysis to be developed which will form part of the final quarter report. Since 31 March 2016 the Community Health Partnerships were dissolved and for the purposes of this report are called Angus, Dundee or Perth & Kinross Partnership. A number of services are now hosted in different Partnerships which may have an impact on average figures i.e. Perth and Kinross Community Health Partnership now host Learning Disabilities and Mental Health In- Patient Services, which historically tend to have higher levels of absence. 2.2 Sickness Absence Activity All areas Directorates/Partnerships have developed action plans to ensure that there is ongoing activity in relation to absence management. Absence activity by each area for the quarter is detailed in Table 2 (Source: NHS Tayside HR Tracker 2016/17) Table 2 Absence Activity by Area Quarter /17 Attendance Improvement Standard Dismissed Long Term Sick Leave Dismissed Short Term Sick Leave Angus Partnership <5 0 0 Dundee Partnership Perth & Kinross 17 <5 <5 Partnership Access Directorate <5 <5 0 Medicine Directorate 9 <5 0 Surgical & Theatres Specialist Services Operations Directorate 5 <5 0 Mental Health <5 0 0 Directorate Corporate & Board <5 0 0 Tayside Communities Table 3 details the overall NHS Tayside quarterly absence rates, calculated on hours lost (Source: NHS Tayside Absence Information Reports October December 2016) Table 3 Year Quarter 1 Quarter 2 Quarter 3 Quarter / % 4.64% 4.79% 2015/ % 4.70% 5.02% 5.22% 2014/ % 4.69% 4.98% 4.95% Directorates and Health and Social Care Partnerships continue to support managers to ensure that they have the skills and knowledge to address attendance issues in a pro-active, but supportive way. Managers work with HR colleagues to address hot-spot areas where there may be specific issues arising and action plans are developed to address these e.g. within Maternity Services have been undertaking a piece of work around stress using the NHS Tayside Work Pressure Profile Questionnaire which has been designed to work through the 6 Management Standards for Stress as defined by the Health and Safety Executive 2

108 which identified areas of workplace and personal stress. Within the Dundee Midwifery Unit, this has seen absence reduce from 13% down to 2.30% in January. Maternity services also have a significant number of staff on long term absence for a variety of reasons, including surgical procedures which are being managed in accordance with the Promoting Attendance at Work policy, including supporting staff back to work making adjustments where possible. Learning Disabilities In-patient Services have historically had high levels of absence and the attached action plan (appendix 1) describes the work that is on-going in that area. There have been significant improvements in a number of departments as a result of this refreshed focus. Within Support Services, there have been a number of changes to the management team and individuals have now been given specific portfolios to manage absence. A draft action plan for Domestic and Portering staff is attached and this will be further developed (appendix 2). In relation to work-related stress generally, individuals are met with within a short timescale of reporting sick to discuss their issues and how these can be addressed. This is also reflected in pieces of work in wider teams where there have been particular stressors identified. (As detailed above). Staff are also encouraged to pro-actively manage their well-being by utilising the Well-being Centre and the Live Positive Mental Health well-being tool. Table 4 details the key reasons for absence across NHS Tayside (Source NHS Tayside Information Report December 2016) Table 4 Reasons of Absence Reason Quarter 1 Quarter 2 Quarter 3 Quarter /16 average Stress/Anxiety/ Depression Unknown Cause Other known cause Musculoskeletal Gastro-Intestinal Back Problems Injury Fracture Cold/Flu National Absence Rates Comparison The national average absence rate across NHS Scotland for Quarter 3 was 5.35% and NHS Tayside s performance continues to be below the average at 4.81%. Out of the 22 NHS Boards NHS Tayside was the 8 th placed performing Board for Quarter 3. 3

109 3. RECOMMENDATIONS The Committee is asked to note the content of the report. A further update will be brought to a future Staff Governance Committee. 4. REPORT SIGN OFF George Doherty Director of Human Resources Jackie Bayne HR Business Lead March

110 Appendix 1 - Promoting Attendance at Work Action Plan Learning Disabilities 2016/17 Action No. Action 1. Training Lead Responsibility Target Completion Date Measures of success All staff with responsibility for managing absence to attend PAAW awareness session. (NB Only if they did not attend session held with FS in 2016.) RB March 2017 Staff involved in absence management are trained and demonstrate appropriate application of PAAW Policy. Development of training plan for Band 5/6 staff who will conduct RTW discussions or be nurse in charge and require to be familiar with policy and reporting arrangements. RB/FS March 2017 Staff involved in absence management are trained and demonstrate appropriate application of PAAW Policy. 2. Staff Communication All staff receive copy of PAAW advice for employees RB 31 December 2016 All staff in possession of guidance and demonstrate awareness of responsibilities. Absence to be discussed at Team Meetings RB/SCNs Each team meeting Awareness of absence issues raised. Inclusion of sickness absence procedures in induction process. RB/SCNs On commencement for new starts All new staff can demonstrate awareness of policy 3. Policy Compliance 5

111 Return to Work discussions completed for all staff who have been absent. All staff with responsibilities for absence management On-going Staff met with timeously on return. Pro-formas completed RTW date recorded on SSTS system / BOXI reports Records printed from BOXI and shared with staff at discussion. All staff with levels of absence which are causing concern to be invited to a formal review meeting with CTM/HR RB/FS January 2017 Staff are given opportunity to discuss any concerns/issues which are impacting on their health and ability to attend work regularly. Appropriate support provided where necessary e.g. OH/Wellbeing centre input. Escalation of cases to CTM when unacceptable levels of absence are evident. SCNs On-going Absence monitored regularly with input from HR Regular scrutiny of PAAW compliance 4. Alternative Duties/Adjustments RB/FS 6 monthly or more frequent if necessary SCNs given the opportunity to discuss cases and seek further support if necessary. All staff being treated equitably. Consideration of alternative duties/roles. Advice to be sought from OH/Fit for Work if necessary. RB/SCNs On-going Staff supported to return to work without unnecessary delay. Reduction in length of absences. Lessening of impact on staff sick pay Occupational Health referrals consider if necessary. Return to work not to be delayed to wait on OH advice if not necessary. RB/SCNs On-going Reduction in delays to return to work following long term absence. 6

112 Consider referring staff to this service after 4 weeks absence. 5. Health Promotion/Support RB/SCNs When opportunity arises and staff meet referral criteria Staff are provided with sign-posting/advice to support health and wider social issues. Promote flu immunization programme to staff print off Vital Signs to display in Ward areas SCNs When campaign launched Staff are aware of opportunities to access immunisation. Utilise Live Positive tool kit for mental illness when necessary RB/FS/SCNs As and when required Awareness of tool kit is raised and staff are provided with support/signposting for mental health issues. Promotion of Well-being Centre RB/FS/SCNs As and when required Awareness of service is on-going and staff are encouraged to utilise service to support with all aspects of well-being. 7

113 Appendix 2 - Draft Promoting Attendance at Work Action Plan Support Services (Portering and Domestic Services) /17 Action No. Action 1. Training Lead Responsibility Target Completion Date Measures of success Training needs analysis to be undertaken to identify any gaps in training. SL September 2017 Staff involved in absence management are trained and demonstrate appropriate application of PAAW Policy. Band 3 and 5 staff have ability to provide a supportive return to work. Case Scenarios to be discussed at team meetings for sharing of learning SL Monthly meetings Increase in consistency of application of policy. 2. Staff Communication Absence to be discussed at Team Meetings SL/Direct Reports Each team meeting Awareness of absence issues raised. Inclusion of sickness absence procedures in induction process. SL/Direct Reports On commencement for new starts All new staff can demonstrate awareness of policy 3. Policy Compliance Return to Work discussions completed for all staff who have been absent. All staff with responsibilities for absence management On-going Staff met with timeously on return. Pro-formas completed and of a high quality standard. RTW date recorded on SSTS system / BOXI reports 8

114 Records from BOXI shared with staff at discussion. Hot-spots are identified and any themes highlighted to allow pro-active approach to management. E.g. stress, MSK issues All staff with levels of absence which are causing concern to be highlighted to managers Escalation of cases to Senior Manager when unacceptable levels of absence are evident. Review of Monthly Sickness Monitoring Tool. SL/Direct Reports SL/HR All staff with responsibilities for absence management. SL On-going On-going On-going March 2017 Action plans developed to address any specific issues e.g. refreshing any required training i.e. manual handling Action plans to be developed for staff whose level of absence causes concern in accordance with Promoting Attendance at work Policy. Input from HR team Managers given the opportunity to discuss cases and seek further support if necessary. All staff being treated equitably. SL to discuss the tool with Systems and Performance Manager to determine effectiveness and consistency of use within service. 4. Alternative Duties/Adjustments Consideration of alternative duties/roles. Advice to be sought from OH/Fit for Work if necessary. All staff with responsibilities for absence management On-going Staff supported to return to work without unnecessary delay. Reduction in length of absences. Lessening of impact on staff sick pay Occupational Health referrals consider if necessary. Return to work not to be All staff with responsibilities for absence On-going Reduction in delays to return to work following long term absence. 9

115 delayed to wait on OH advice if not necessary. management Consider referring staff to Fit For Work service after 4 weeks absence. All staff with responsibilities for absence management When opportunity arises and staff meet referral criteria Staff are provided with sign-posting/advice to support health and wider social issues. 5. Health Promotion/Support Utilise Live Positive tool kit for mental illness when necessary SL/Direct Reports As and when required Awareness of tool kit is raised and staff are provided with support/signposting for mental health issues. Promotion of Well-being Centre SL/Direct Reports As and when required Awareness of service is on-going and staff are encouraged to utilise service to support with all aspects of well-being. Use of local groups to discuss hotspot areas and develop actions to address these. SL/Direct Reports As and when required Opportunity for staff to feed into discussions and assist in the development of action plans. 10

116 Please note any items relating to Staff Governance business are embargoed and should not be made public until after the meeting Item SGC/2017/08 Staff Governance Committee 14 March 2017 RECRUITMENT ACTIVITY 1. SITUATION AND BACKGROUND Recruitment activity is reported to the Committee on a quarterly basis. Recruitment reports provide information over a 12 month rolling period rather than single quarters to assist the Committee identify trends. This report highlights recruitment information for quarter 3, October to December 2016 and recruitment information from January 2016 to illustrate the trends over the period. 2. ASSESSMENT 2.1 Overview of Recruitment Appendix A shows the total number of posts approved for recruitment in quarter 3. The number of posts approved for recruitment in quarter 3 was 434. This figure is broadly comparable with quarter 3 last year (456). Approved posts in quarter 3 drop due to the time of year and December being known as a poor month for recruiting and attracting suitable candidates. Appendix B describes the number of posts vacant at the end of each quarter by job family. The trend by job family remains broadly consistent over the period as does the overall percentage of posts vacant over the last three (Q3 64%: Q2 61% and Q1 62%). Appendix C details posts vacant by Directorate and IJB with Dundee IJB recording the highest number of vacant posts at the end of December 2016 followed by the Medicine Directorate. Appendix D is an analysis of nursing and midwifery posts approved for recruitment. The drop in quarter 3 can be explained by the intake of Newly Qualified Nurse Practitioners from the local universities and the time of year. Appendix E1 highlights nursing and midwifery posts approved for recruitment by Directorate and IJB with Appendix E2 outlining approved nursing and midwifery posts by band range. Appendix F is an analysis of vacancies filled by internal versus external candidates and continues to highlight the number of internal candidates appointed to posts. Medical and dental posts approved for recruitment is detailed in Appendix G. Medical vacancies do not show the same drop in quarter 3 as gaps in service linked to the February changeover are advertised at this time. 1

117 Appendix H outlines recruitment by Directorate/IJB and medical grade. Appendix I and J details the vacancy rate for medical and non-medical vacancies. As the vacancy rate is a calculation at a specific point in time it can be influenced by timing issues i.e. a post has been offered but the individual has not yet started in post and therefore, is still classed as a vacancy. Mental Health (5.88%) and Dundee IJB (10.20%) recorded the highest vacancy rate for medical vacancies this quarter. Mental Health continues to have vacancies however, Dundee IJB vacant posts in quarter 3 have been filled with one post re-advertised. 3. RECOMMENDATAIONS The Staff Governance Committee is asked to note the information outlined in this report. 4. REPORT SIGN OFF Valerie Beattie Head of HR ~ Resourcing George Doherty Director of HR&OD 28 th February,

118 Appendix A Posts Approved for Recruitment - excluding Medical & Dental January 2016 to December Median Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec Quarter 4 Quarter 1 Quarter 2 Quarter National Definition: A post which has been cleared for advert after being through the redeployment process (internal or external advert) and remains a vacancy until an individual starts in the post.

119 Appendix B Vacancies (excluding medical and dental) by Job Family as at end of Quarter Nursing and Midwifery 56 Support Services Allied Health Profession Administrative Services Health Science Services Other Therapeutic Dental Support Other Series1 Series Vacancies (excluding medical and dental) by Job Family as at end of Quarter Nursing and Midwifery 56 Administrative Services Allied Health Profession Support Services Healthcare Sciences Other Therapeutic 5 5 Dental Support Medical Support Series1 Series2 Vacancies (excluding medical and dental) by Job Family as at end of Quarter Vacancies (excluding medical and dental) by Job Family as at end of Quarter Nursing and Midwifery 60 Administrative Services Allied Health Profession Support Services Other Therapeutic Healthcare Sciences Dental Support Personal And Social Care Series1 Series Nursing and Midwifery Administrative Services Support Services Allied Health Profession Other Therapeutic 16 Healthcare Sciences Personal And Social Care Dental Support Other Series1 Series2 National Definition: A post which has been cleared for advert after being through the redeployment process (internal or external advert) and remains a vacancy until an individual starts in the post.

120 Appendix C Vacancies (excluding medical and dental) by Group/CHP as at end of Quarter Vacancies (excluding medical and dental) by Group/CHP as at end of Quarter Access Directorate Operations Directorate Surgery & Theatres Directorate Medicine Directorate IJB - Perth IJB - Dundee IJB - Angus Corporate & Board Specialist Service Directorate Mental Health Directorate Series1 Series Medicine Directorate IJB - Dundee Access Directorate Surgery & Theatres Directorate Operations Directorate IJB - Perth Mental Health Directorate Specialist Service Directorate Corporate & Board IJB - Angus Tayside Community Directorate Series1 Series2 Vacancies (excluding medical and dental) by Group/CHP as at end of Quarter Vacancies (excluding medical and dental) by Group/CHP as at end of Quarter Medicine Directorate Surgery & Theatres Directorate IJB - Dundee IJB - Perth Operations Directorate Specialist Service Directorate Access Directorate Corporate & Board Tayside Community Directorate IJB - Angus Mental Health Directorate Series1 Series IJB - Dundee Medicine Directorate Operations Directorate Surgery & Theatres Directorate Access Directorate IJB - Perth Corporate & Board Specialist Service Directorate Mental Health Directorate IJB - Angus Tayside Community Directorate Series1 Series2 National Definition: A post which has been cleared for advert after being through the redeployment process (internal or external advert) and remains a vacancy until an individual starts in the post.

121 Appendix D Posts Approved for Recruitment - Nursing & Midwifery Vacancies January 2016 to December Median Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec Quarter 4 Quarter 1 Quarter 2 Quarter National Definition: A post which has been cleared for advert after being through the redeployment process (internal or external advert) and remains a vacancy until an individual starts in the post.

122 Appendix E1 Posts Approved for Recruitment - Nursing & Midwifery by Group/CHP Quarter % 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Posts Approved for Recruitment - Nursing & Midwifery by Group/CHP Quarter % 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Posts Approved for Recruitment - Nursing & Midwifery by Group/CHP Quarter Posts Approved for Recruitment - Nursing & Midwifery by Group/CHP Quarter % 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% % 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

123 Appendix E2 Posts Approved for Recruitment - Nursing & Midwifery by Band Quarter Posts Approved for Recruitment - Nursing & Midwifery by Band Quarter % % % 80.0% % 80.0% 70.0% % % 50.0% 40.0% 30.0% 20.0% 10.0% % 50.0% 40.0% 30.0% 20.0% 10.0% 0 Band 5 Band 6+ Band % 0 Band 5 Band 6+ Band % Posts Approved for Recruitment - Nursing & Midwifery by Band Quarter Posts Approved for Recruitment - Nursing & Midwifery by Band Quarter % % Band 5 Band 2-4 Band 6+ Other % 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Band 5 Band 6+ Band % 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

124 Vacancies Filled (excluding Medical & Dental) by Job Family and by Internal or External Appointee Appendix F Job Family Quarter 4 Quarter 1 Quarter 2 Quarter 3 External Internal External Internal External Internal External Internal Administrative Services Allied Health Profession Health Science Services Dental Support 2 1 Nursing and Midwifery Other Therapeutic Support Services Grand Total Quarter 4 Quarter 1 Administrative Services Allied Health Profession Health Science Services Dental Support Nursing and Midwifery Other Therapeutic Support Services External Internal Administrative Services Allied Health Profession Health Science Services Dental Support Nursing and Midwifery Other Therapeutic Support Services External Internal Quarter 2 Quarter 3 Administrative Services Allied Health Profession Health Science Services Dental Support Nursing and Midwifery Other Therapeutic Support Services External Internal Administrative Services Allied Health Profession Health Science Services Dental Support Nursing and Midwifery Other Therapeutic Support Services External Internal

125 Appendix G Medical & Dental Posts Approved for Recruitment January 2016 to December Median Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec Quarter 4 Quarter 1 Quarter 2 Quarter National Definition: A post which has been cleared for advert after being through the redeployment process (internal or external advert) and remains a vacancy until an individual starts in the post.

126 Medical & Dental Posts Approved for Recruitment by Group/CHP January 2016 to December 2016 Appendix H Group Quarter 4 Quarter 1 Quarter 2 Quarter 3 Total NHS Tayside Access Directorate Corporate & Board Medicine Directorate Mental Health Directorate IJB - Angus 1 1 IIJB - Dundee IJB - Perth Specialist Service Directorate Surgery & Theatres Directorate Tayside Community Directorate Medical & Dental Posts Approved for Recruitment by Grade January 2016 to December Grade Quarter 4 Quarter 1 Quarter 2 Quarter 3 Total NHS Tayside Consultant Others Training Grades National Definition: A post which has been cleared for advert after being through the redeployment process (internal or external advert) and remains a vacancy until an individual starts in the post.

127 Appendix I Medical Vacancy Rates Quarter 4 Quarter 1 Quarter 2 Quarter 3 NHS Tayside 1.30% 3.16% 2.15% 2.94% Q1 Access Directorate 1.72% 1.69% 0.85% Q2 Corporate & Board 3.57% Medicine Directorate 0.79% 3.89% 3.72% 4.48% Mental Health Directorate 3.16% 14.55% 7.02% 5.88% IJB - Angus 1.27% IJB - Dundee 11.90% 4.65% 10.20% IJB - Perth 5.00% 6.19% 2.86% Specialist Service Directorate 1.04% 1.53% 0.52% 1.03% Surgery & Theatres Directorate 0.68% 1.37% 1.37% 3.33% Tayside Community Directorate National Definition: A post which has been cleared for advert after being through the redeployment process (internal or external advert) and remains a vacancy until an individual starts in the post.

128 Appendix J NHST Vacancy Rates - non medical Group Level Quarter 4 Quarter 1 Quarter 2 Quarter 3 Access Directorate 3.90% 3.44% 1.56% 1.84% Corporate & Board 2.18% 1.68% 2.46% 2.04% Medicine Directorate 2.19% 3.78% 4.28% 2.26% Mental Health Directorate 1.42% 15.22% 7.62% 4.69% IJB - Angus 3.78% 1.69% 2.53% 0.91% IJB - Dundee 2.72% 3.83% 3.78% 3.82% IJB - Perth 3.58% 2.62% 2.53% 1.53% Operations Directorate 2.79% 2.18% 1.39% 2.18% Specialist Service Directorate 2.15% 2.75% 2.83% 1.59% Surgery & Theatres Directorate 3.63% 3.53% 3.56% 2.36% Tayside Community Directorate 2.51% 5.69% 2.02% NHS Tayside 2.78% 3.18% 2.98% 2.19% Job Family Quarter 4 Quarter 1 Quarter 2 Quarter 3 Administrative Services 1.33% 2.34% 2.48% 1.66% Allied Health Profession 3.94% 3.29% 3.38% 2.86% Dental Support 3.85% 2.48% 2.49% 0.49% Healthcare Sciences 3.89% 4.33% 1.74% 2.75% Medical Support 26.32% Nursing/Midwifery 2.77% 3.53% 3.48% 1.99% Other Therapeutic 3.70% 4.76% 4.57% 5.39% Support Services 3.20% 1.97% 1.63% 2.20% Other % % NHS Tayside 2.78% 3.18% 2.98% 2.19%

129 Please note any items relating to Staff Governance business are embargoed and should not be made public until after the meeting Item 9.3 SGC/2017/10 Staff Governance Committee 14 March 2017 VALUING PEOPLE VALUING STAFF EXPERIENCE & ENGAGEMENT imatter AS A VEHICLE TO UNDERPIN AN IMPROVEMENT CULTURE 1. SITUATION AND BACKGROUND This report has been prepared to inform the Staff Governance Committee about progress to date in relation to implementation of the imatter Staff Experience Continuous Improvement Model in line with our national plan. This report does not provide information as to Directorate level action planning and development which is owned at local level. 2. ASSESSMENT 2.1 National Measure Scottish Government has now confirmed that the previous national annual Staff Survey be discontinued and that future national staff experience be measured using the imatter Continuous Improvement Model supplemented by a short complementary questionnaire (Appendix 1). Staff in all NHS Boards will participate in imatter on an annual basis supporting continuous improvements in staff experience and engagement. This also supports NHS Tayside s ongoing commitment to developing a healthy organisational culture which is a priority of both NHS Tayside (through our People Matter Strategy framework) and of Everyone Matters: 2020 Workforce Vision. 2.2 NHS Tayside Implementation in 2017 In 2017 all NHS Tayside-employed staff will have the opportunity to participate in imatter. A Vital Signs was issued to all staff in February 2017 (Appendix 2) highlighting progress to date as well as next steps. In addition both Dundee and Angus Health and Social Care Partnerships have advised that Social Care staff in integrated teams and/or assessment services will be participating together with NHS staff in these cohorts, offering an opportunity to understand where staff are currently (a baseline) as new working arrangements become embedded and for a more inclusive approach for employee engagement across the Partnerships. The roll-out is split into nine cohort runs with iterations of the Board report being issued following each cohort s participation. 1

130 It is therefore anticipated that by the end of 2017 c.15,000 staff will have had the opportunity to participate in imatter and have their views included in team, Directorate/ Health & Social Care Partnership and Board-level imatter reports. 2.3 Embedding and Sustaining imatter Early discussions have commenced on the arrangements for embedding and sustaining imatter following full implementation across NHS Tayside. Discussions and planning will continue with stakeholders over the coming months. 2.4 Local Partnership Forums As previously agreed, details on implementation and reports in each Directorate should be sought, through the Area Partnership Forum, from the Co-Chairs of each Local Partnership Forum. 3. RECOMMENDATIONS The Staff Governance Committee is asked to: Note the contents of the Scottish Government correspondence; Note the inclusion of Social Care staff in Dundee and Angus Health & Social Care Partnership cohorts; Note the commencement of discussions on the embedding and sustaining of imatter; Celebrate what has been achieved to date. 4. REPORT SIGN OFF Mr George Doherty, Director of HR & OD Ms Jenni Jones, Associate Director - Development Ms Diane McLeish Organisational Development Lead Ms Lucy Archer imatter Programme Manager March

131 Health Workforce & Strategic Change Directorate Workforce Practice Unit T: E: NHSScotland Board: Human Resource Directors Employee Directors Copy: NHSScotland Board: Chairs Chief Executives Members of the Scottish Partnership Forum Members of the Scottish Workforce and Staff Governance Committee 13 December 2016 Dear Colleagues NHSSCOTLAND NATIONAL STAFF EXPERIENCE MEASUREMENT Further to my letter of 3 December 2015, I am writing to advise you of the new arrangements for measuring national staff experience. It has been agreed that the previous national annual Staff Survey be discontinued and that future national staff experience be measured using the imatter Continuous Improvement Model (imatter) supplemented by a short complementary questionnaire. The complementary questionnaire will be distributed to all staff via the NHSScotland Employee Engagement IT Portal, the system through which imatter is run, and will cover areas not deemed suitable for inclusion in the current imatter questionnaire process and subsequent Team reports and discussions. More detailed information on the new arrangements are provided at Annex A, which you may also find helpful as a briefing note for relevant staff. National and Board level reports, which will include Directorate level information, will provide a full overview of staff experience in the general areas previously covered by the national Staff Survey and will be reported to Scottish Workforce and Governance Committee (SWAG). These will be publically available in early 2018 (anticipated end February 2018). As with the development of the imatter Continuous Improvement Model, these new arrangements have also been developed in full Partnership and through focussed engagement with the HR community and local and national staff side representatives. This new approach comes with the full support of these communities and has been endorsed by the Scottish Workforce and Staff Governance Committee, and approved by the Cabinet Secretary for Health and Sport. Actions for Boards We anticipate that the complementary survey questionnaire will be available for completion in late 2017 but exact dates will be confirmed in due course. As you will be aware, each NHSScotland Board has committed to having all its staff registered with imatter by end St Andrew s House, Regent Road, Edinburgh EH1 3DG

132 June To ensure we achieve a national staff experience measure within the specified timescales it is essential that this is achieved - i.e. that every NHSScotland employee, regardless of their working arrangements (for example, working under IJB arrangements), is checked in to the imatter system by end June 2017, in line with Board Implementation Plans. We are therefore seeking your continued support and engagement with imatter colleagues to ensure that you successfully deliver on your imatter implementation plans. Through Board implementation plans and information provided to the imatter Programme Implementation Group, we are not aware of any Board that is not currently projecting delivery in line with this ministerial commitment. However, any Boards who anticipate or encounter difficulties are asked to advise us at the earliest possible stage to allow us to jointly have a discussion about their proposals to mitigate any identified risks. Staff Governance Standard Monitoring In recognition of our new approach to measuring national staff experience, it is also our intention to refresh our approach to Staff Governance Standard Monitoring to ensure that the process is adding value and driving improvement in the context of the work on imatter and wider emerging policy landscape. We are currently working in Partnership to develop proposals to ensure that we have a mechanism in place which remains fit for purpose and which provides meaningful and relevant information both nationally and locally. With this in mind SWAG Secretariat has agreed that the Scottish Government does not undertake a traditional annual Staff Governance Monitoring exercise for 2016/17. This will allow this transitional year to focus on fully implementing imatter and developing a complementary Staff Governance Standard Monitoring process as outlined above. We will, however, need to continue to gather relevant information required to provide us with a picture of Health Board progress in delivering the Staff Governance Standard and inform the Annual Review process and will write to each Board in January 2017 to request this. I hope this clarifies the current position and welcome your support in communicating this information to relevant staff. Yours sincerely Malcolm Summers Head of Workforce Practice Unit St Andrew s House, Regent Road, Edinburgh EH1 3DG

133 Background ANNEX A Low participation rates in the annual NHSScotland Staff Survey and the expected follow up actions for Boards have been the subject of on-going partnership discussions over recent years. These highlighted the limitations of this method of measuring, monitoring and addressing staff experience. Boards told us that local resources could be more effectively used to support the imatter programme without duplicating staff experience activity with the on-going staff survey. This resulted in an agreement to pause the annual national Staff Survey in 2016 to help facilitate full Board roll out of the imatter Continuous Improvement Model; to provide space for consideration of different options with a view to refreshing our approach to measuring national staff experience; and, for proposals for a new measure to be developed. National Staff Experience Measurement through imatter To date, the overall response rate for all who have participated in the imatter core questionnaire is 66%. This compares with the 2015 staff survey response rate of 38%, which represented the highest response rate to the national Staff Survey since its inception. The imatter model was developed by the staff for the staff primarily as a local continuous improvement staff experience tool, however, the model was always developed with the potential for it to be the replacement of the national Staff Survey. Using the imatter model as our new staff experience measure builds on the early success of the project in transforming the way in which we engage with our staff. It provides an alternative way of measuring staff experience at a national level through the existing imatter core questionnaire, which covers the majority of areas previously addressed by the annual national Staff Survey, complemented by an additional survey, covering a set of questions deemed inappropriate for discussion at team level. This combination will provide a holistic overview of staff experience nationally which encompasses the areas previously covered by the national Staff Survey. Additional survey questionnaire The imatter core questionnaire addresses around 95% of the areas of staff experience previously covered by the national Staff Survey. However, questions relating to the following areas are not covered: bullying and harassment abuse and violence from patients and public discrimination whistleblowing resourcing The continued importance of monitoring these areas has been identified, but due to their sensitive nature, it is recognised that they would be unsuitable for inclusion in the current imatter questionnaire process and subsequent team level reports for team discussions and action planning. It has therefore been agreed that a short additional survey questionnaire covering these areas be run through the NHSScotland Employee Engagement IT Portal. This will allow this information to be gathered to complement the core imatter questionnaire whilst at the same time providing a baseline question set to allow consistent monitoring as we go forward. St Andrew s House, Regent Road, Edinburgh EH1 3DG

134 Staff Groupings/Demographics and confidentiality The additional survey will be reported to provide National and Board level reports. They would show results broken down by Directorate, staff group and contain relevant demographic information. As with previous staff survey information, this will not be available at team level nor shown where confidentiality could potentially be compromised. Timescales imatter continues to be rolled out in phases in all 22 Boards and full implementation is due to be completed by the end of For the purposes of a national measure this would mean that all the information from the current imatter questionnaire would be available for reporting in early The additional complementary survey would be developed and functionality tested with some Boards in 2017 with a view to rolling this out nationally in late This would then complement the 2017 imatter results to provide a complete national and local overview of staff experience in early Next steps We will continue to engage with Boards and work in partnership to continually develop all aspects of our approach to staff experience. To further ensure quality of information and reporting, consideration will be given to: the future optimum timeframe of measuring and reporting on local and national staff experience including the timing of the imatter and additional survey how the staff experience measure can become an integral part of staff governance monitoring. St Andrew s House, Regent Road, Edinburgh EH1 3DG

135 vital signs Positive Staff Experience Supports Improved Care The imatter Staff Experience Continuous Improvement Model, which is designed to help individuals, teams and Health Boards understand and improve staff experience, has now been rolled-out to NHS Tayside staff in the Operational Unit and Corporate Directorates over the past two years. imatter is for use at team level and can promote openness and transparency about your experience at work. It recognises that there is already a lot that is good about our teams and our workplace, but we should always be looking to learn and improve. Ownership of the questionnaire and of planning improvements in what you do on a day-to-day basis sits with you, in your teams. The NHS Tayside imatter Board report for 2016 has now been issued and is available through Staffnet >Our Websites > imatter What we have already learned: Recognition of what we do well: Recognition of areas where we need to improve: l l l l Direct line managers are sufficiently approachable and care about their team s health and wellbeing We have confidence & trust in direct line managers There is clarity about duties and responsibilities We understand how our roles contribute to the goals of the organisation l l l l Time and resources to support learning growth Staff feeling Involved in decisions relating to the organisation Visibility of, and confidence and trust in, senior managers responsible for the wider organisation Improve how performance is managed within the organisation n imatter n Issue 895 n February 2017

136 How are we responding to your feedback? l l l l A series of Value Your NHS staff drop-in sessions were held throughout 2016 across Tayside. These offered staff the opportunity to meet with the Chairman, Chief Executive and Directors for an informal Q&A conversation. Regular newsletters were circulated to all staff to share the feedback from the sessions. A People Management Learning Directory is currently under development. 100 supervisors and managers have access to the Directory on Staffnet as part of the pilot phase. Consideration will be given to extending the Directory to a wider audience following further evaluation of the pilot. The new STAR (STaff Appreciation and Recognition Awards) offer staff and the public a chance to recognise an individual, service or team for delivering outstanding patient care or going the extra mile in their job. NHS Tayside has embarked on a piece of work to better understand the culture of the organisation. This brings together information from a number of sources including imatter data and responses from a survey on culture issued to all staff in late imatter Next steps? Scottish Government has now confirmed that imatter has now replaced the previous national Staff Survey as the measure of staff experience. Staff in all NHS Boards will participate in imatter on an annual basis supporting continuous improvements in staff experience and engagement. In 2017 all NHS Tayside-employed staff, along with some local authority colleagues in the Health and Social Care Partnerships will have the opportunity to participate in imatter. This supports NHS Tayside s ongoing commitment to developing a healthy organisational culture which is a priority of both NHS Tayside (through our People Matter Strategy framework) and of Everyone Matters: 2020 Workforce Vision. How can imatter support a healthy workplace culture? imatter can support you in your teams to reflect on your experiences over the past year, celebrate what you do well, and highlight areas for improvement that will enhance your experience at work. We encourage all of you to participate in imatter over the coming months. Let s all take the opportunity to influence how we work together in our teams, and in NHS Tayside. For further information you can visit our imatter page: Staffnet > Our Websites > imatter George Doherty Director of HR & Organisational Development Jenny Alexander Partnership Facilitator n imatter n Issue 895 n February 2017

137 Please note any items relating to Staff Governance business are embargoed and should not be made public until after the meeting Item 9.4 SGC/ Staff Governance Committee 14 March 2017 VALUING PEOPLE DEVELOPMENT OF A WHOLE SYSTEM/PERSONAL DEVELOPMENT REVIEW (PDR) & PERSONAL DEVELOPMENT PLAN (PDP) IMPROVEMENT PLAN FOR 2016/17 - UPDATE 1. SITUATION & BACKGROUND It is well documented that culture impacts directly on quality of care, safety and organisational effectiveness 1. A healthy culture is a necessary condition for the organisation to succeed in implementing its strategy, with leadership being the most significant influence. The developing our culture work will be bringing forward proposals for developing and implementing an effective collective leadership strategy and makes reference to the strong links between culture and a commitment to ensure all staff have annual meaningful Personal Development Review (PDR)/Personal Development Planning (PDP) discussions. For the majority of NHS employees the eksf system is currently the only way we can actually measure PDP/PDR activity across NHS Tayside and there has been evidence of a steady decline since 2012 when the Scottish Government Health Department (SGHD) announced that KSF would no longer be included in Boards HEAT targets as staff appraisal should be mainstreamed into all line managers areas of responsibility. Since the SGHD directive, line managers and staff have been provided with PDR/P appraisal skills workshops and learning resources to support them with this important part of their role. In January 2016 a session was facilitated with NHS Tayside s Senior Management Team to discuss and agree how, as a system, we could improve on the PDR/PDP activity. An Improvement Plan was produced with an agreed stretch goal stating 80% of staff will have an up to date PDR/P in place by the end of the year. As at the end of January 2017 the percentage was sitting at 38.6% monthly workshops have been delivered on Appraisal Skills with more planned and ongoing support is being provided to managers and teams across the organisation, examples include: Tayside Child Health Teams; Ward 42, Ninewells Hospital; Telecoms; Blood Sciences; Oncology; Wards 1,2,3,4, 23A and 33, Ninewells Hospital; CAMHS; Rohallion, Murray Royal Hospital; Medical Physics, Ninewells Hospital; TORT, Ninewells Hospital; Plaster Room, Ninewells Hospital; Carseview; CIU; Strathmartine Hospital, A & E, Pharmacy 1 Regina Eckhert, Michael West, David Altman, Katy Steward and Bill Pasmore (2014) Delivering a Collective Leadership Strategy for Health Care, Centre for Creative Leadership/The King s Fund 1

138 Department, Dental Services Healthcare Support Workers Development session Over the last 12 month period Directors have received monthly detailed eksf activity reports and the Development team has continued to support line managers, teams and individuals. The executive summary for January 2017 is detailed below eksf Update - as at Jan 2017 Cost Centre 4 PDR PDP HC Y % N % Y % N % NHS Tayside % % % % Access Directorate % % % % Corporate & Board % % % % IJB - Angus % % % % IJB - Dundee % % % % IJB - Perth % % % % Medicine Directorate % % % % Mental Health Directorate % % % % Operations Directorate % % % % Specialist Service Directorate % % % % Surgery & Theatres Directorate % % % % Tayside Community Directorate % % % % 2. ASSESSMENT Regular feedback from managers and staff highlights frustrations with the national eksf system, and eksf which is scheduled to be decommissioned in March The redesign of services, changing teams and Health & Social Care integration, is now having an impact on the accuracy of the information held in the eksf system. Under Agenda for Change, 58% of our workforce are required to meet professional registration requirements, a major component of the Nursing & Midwifery and Allied Health Professionals revalidation process requires evidence of up to date personal development activity. NHS Tayside monitors the level of compliance, and currently this sits at 91%. 42% of our workforce are governed by the Regulations for Healthcare Support Workers (RHCSW) which sets out the requirements for all our support staff in relation to standards of service delivery and core areas of training and development. NHS Tayside monitors the progress of completing the associated personal development workbooks and we are currently reporting a 92.7% compliance rate. The staff engagement tool imatter also plays a major role in monitoring staff s personal learning and development activity and recent survey analysis from imatter provides NHS Tayside with a 71% scoring against this indicator. 2

139 If we were to adopt a different model and reframe PDP uptake through alternative sources of reliable assurances, we will get a better reflection of the real uptake. 3. RECOMMENDATIONS In light of the aforementioned national and local issues, it is proposed that: With the full support of our staff side representatives and leadership from the Chief Operating Officers, we will build on the current sources of evidence referred to, and align these reporting systems using the imatter toolkit, Nursing & Midwifery, AHP revalidation and RHCSW data, with a sign off section evidencing that staff have had an annual PDR/P discussion with their line manager. A test of this model (using template in Appendix 1) is piloted within a clinical and non clinical area of service. We are keen to explore connections with imatter being the main vehicle to support individual and team development. An evaluation report will be presented back to the Staff Governance Committee in September To provide an assurance regarding progress towards meeting this Staff Governance Standard, the 4 Chief Operating Officers will be required to provide status updates on activity. 4. REPORT SIGN OFF Mr George Doherty, Director of HR & OD Mrs Pat Millar Head of Knowledge & Skills Ms Jenni Jones, Associate Director of Development. March

140 SAMPLE TEMPLATE PDR/PDP SUMMARY DIRECTORATE: Human Resources & Organisational Development (HR OD) TEAM LEADER: PDR/PDP NAME: Staff signature Manager signature Prof Rev* RHCSW** Date Fire Safety Awareness Info Gov CPR VDU TEA "CORE" LEARNING PRO Adult/Child Protection *profession revalidation if applicable **regulations of Healthcare Support Workers Standards if applicable Quality PDR/PDP Conversation 4

141 Please note any items relating to Staff Governance business are embargoed and should not be made public until after the meeting Item 9.5 SGC/2017/12 Staff Governance Committee 14 March 2017 Audit of People Management Practice 1. SITUATION AND BACKGROUND The Staff Governance Committee has requested assurance that key people management practices are being complied with and that when new circulars are issued by the Health Workforce and Strategic Change Directorate there is a proper assessment of any required changes to current practice. This paper seeks to outline a programme of compliance audit during 2017/18 which will look at compliance with existing NHS Tayside employment policies. 2. ASSESSMENT There have been occasions where a failure to adhere to established employment practice or to a policy has led to unacceptable risk to the organisation. Serious breaches can lead to costs via employment tribunals with the added potential reputational for damage to the organisation. The Staff Governance Committee has asked the Human Resources Department establish a process which provides reassurance that good employment practice is being adhered to. The Directorate has piloted a compliance audit process which measured compliance with the Promoting Attendance at Work Policy requirement to have completed Return to Work forms in personal files. The pilot highlighted the usefulness of such audits in identifying areas for improvement and it will now be rolled out across a programme of audit for 2017/18. For 2017/18 in 3 areas; In 2016 the Director of Human Resources instructed that all staff who, from the date of the memo, move onto non-grade protection should receive written confirmation of this. Specimen letters are available in the Organisational Change Policy. A review of adherence to the issue of documentation will be undertaken. As part of the Fixed-Term Contract Policy staff whose contract is not going to be renewed should receive written notification of this. A model letter of expiry is contained within the Policy. A review of adherence to the model letter will be undertaken The Promoting Attendance at Work Policy requires managers to complete Return to Work (RTW) forms following each episode of sickness absence. An RTW form is contained within the Policy. As mentioned earlier in this paper adherence to this aspect of the Policy formed part of the initial test of the assessment tool. It is intended to roll out this review across all of NHS Tayside. This stream will seek to address concerns raised on this topic at the 13 December 2016 meeting of the Staff Governance Committee. 1

142 It is not intended to review every individual use of the above documentation however the audit will cover a cross slice of NHS Tayside. The outcome of the audits will be reported to the Area Partnership Forum (APF), and the Staff Governance Committee (SGC). HR Audit Assessment Form Whilst the audits will give an overview of current practice it will not address changes to practice which may be required as a consequence of new circulars which change current terms and conditions or employment law. The attached HR Audit Assessment Form would enable any changes to current employment practice to be highlighted and allow consideration of how any changes will be communicated. In addition the Form identifies risks to the organisation if adherence to the circular is not achieved and how implementation will be audited. 3. RECOMMENDATIONS An annual update on the use of the HR Audit Assessment Form will be brought to the attention of the APF and SGC. The Assessment Forms will be held centrally by the Director of Human Resources. A six monthly report on the employment compliance audits will be brought to future Staff Governance Committee meetings. 4. REPORT SIGN OFF Christopher Smith Associate Director of HR & OD Date February

143 HR Audit Assessment Form To be completed by HR Director or delegated responsibility prior to communicating changed terms and conditions or employment law to line managers. This in order to assess whether subsequent audit of line manager practice is required. State the changed legislation or terms and conditions. (For terms and conditions consider DLs, STAC (TCS), PIN Policies, CELs and PCS) 1) Does implementation of the new t&cs or employment legislation require a new practice from line managers or a change to current practice of line managers? Yes/No If No then no further action is required in relation audit of line manager practice. If Yes complete questions 2) to 7) 2) State the specific line manager practice that will be necessary for the t&cs or legislation to be correctly implemented. Complete questions 2) to 7) for each separate line manager practice 3) What process will be in place to ensure that all line managers responsible for implementation of changed t&cs or legislation are informed of the new/changed practice and how will it be verified that managers have been informed? 4) What process will be in place to ensure that all line managers responsible for implementation of new or changed t&cs or legislation understand the revised t&cs or legislation and how will it be verified that managers understand? 5) What are the risks, including financial risk, of any line manager failure to implement the ts&cs/legislative change? 6) Is audit of line manager practice both necessary and possible in order to verify implementation of the t&cs/legislation? Yes/No 7) If no audit of line manager practice required why not? If yes what system or process of audit will be implemented to provide assurance that a new line manager practice or a changed line manager practice has happened? T&Cs or Legislation How to verify t&cs or legislation is being applied by line managers Frequency Signed...Date...

144 Item 9.6 Please note any items relating to Staff Governance business are embargoed and should not be made public until after the meeting SGC/2017/13 Staff Governance Committee 14 March 2017 PEOPLE MANAGEMENT LEARNING DIRECTORY 1. PURPOSE OF THE REPORT This report outlines the pilot of a People Management Learning Directory that has been tested within NHS Tayside since 01 July This report seeks to provide an overview of the process and initial findings from the pilot. 2. RECOMMENDATIONS Members of the Staff Governance Committee are asked to: Receive the attached report Consider and agree the transition to phase two of implementing the People Management Learning Directory 3. APPROACH TO THE PILOT PHASE 1 Learners currently identify and access people management training within NHS Tayside through a range of different sources and platforms including: NHS Tayside Training Database, Improvement Academy Website, Staffnet pages, learn-pro, communication, staffnet flyers etc. This training covers a range of management and leadership competencies and is developed and delivered by subject experts across the organisation. Available training includes workshops, seminars, policy awareness and learn-pro modules. The People Management Learning Directory (Appendix 1) provides a framework which assists managers and supervisors to identify the learning opportunities available within NHS Tayside and navigate their way around the development and training appropriate to their role. The Directory was developed in response to local evidence that staff currently find it difficult to navigate the development/training programmes available via many portals. This can be both time consuming and frustrating. There is no single competency framework available and managers can be unsure as to what learning is appropriate for their stage of development. Aims of the People Management Learning Directory: To provide a single framework to assist managers and supervisors in navigating their way around the training available. To signpost managers and supervisors to the training and development that is appropriate to their development needs. It does this by identifying three levels of development; the first being based around developing organisational understanding and awareness of employment policy. The second level provides development in more skills based issues such as undertaking successful investigations, giving feedback, managing change, promoting wellbeing in the workplace. The third stage provides more stretching development on such competencies as developing high performance, engagement and leadership 1

145 Pilot Process - Specialist Services and Access Directorates Across NHS Tayside approximately 1500 staff are considered to be reviewers within the e-ksf system and this indicates the potential cohort who would benefit from the Directory. Through the pilot process 99 managers and supervisors have been provided with access to the Learning Directory. Senior managers within the Specialist Services Directorate expressed interest in testing the Learning Directory and five introductory sessions were held with approximately staff. The purpose of each of these sessions was to share the Directory and describe its purpose and potential benefits. From these sessions a group of 56 managers and supervisors within the Specialist Services Directorate expressed interest in being participants in the pilot and began accessing the Directory from 01 July Through word of mouth between the managers in Specialist Services and Access Directorate, it was agreed that the pilot would be extended to the Access Directorate. The manager group in Access had heard good initial reports about the Directory Pilot from colleagues and were both enthusiastic and keen to be involved in the pilot phase. This commenced on 01 September 2016 and included 43 managers and supervisors. An oversight group including training providers, users and partnership representation was established to provide guidance, suggestions and oversight to the operational work of implementing the Directory pilot. Pilot Assessment Initial assessment of the Directory pilot was undertaken in January and February (Appendix 2) This was undertaken via feedback questionnaires a focus group analysis of training course attendance rates. assessing the resource required to maintain and update the Directory The assessment sought to determine the benefits of the Directory itself as a tool, not the training within it as the Directory doesn t influence or shape the training that is currently developed and delivered. Perceived Benefits 1) Building an Awareness of training resources available. The Directory was successful in heightening awareness of the range of training available within NHS Tayside within the area of People Management. 60% of questionnaire respondents reported that the Directory made them aware of learning opportunities that they wouldn t have otherwise known about. 2) Creating a user friendly portal Through electronic links, the Directory took users to the relevant booking information or login page, saving significant time searching various platforms. The ability of the Directory to gather up and present what is out there in one place was regarded as a significant benefit. Information is based in the one area and you know where to look Participants suggested that a similar directory approach would be beneficial to collate training available in other areas of manager and staff practice, eg health and safety, e-systems, statutory and mandatory etc. It was suggested that a user friendly hub and spoke model could provide a front page to the whole package of training available to managers, making clear was is on offer in each section. 3) Supporting individuals to identify training appropriate to their role or address identified individual need 2

146 The Directory was identified as beneficial to users in a range of circumstances in which they were seeking to identify appropriate learning supporting and complementing personal development and review discussions with staff supporting future career development opportunities supporting individual performance in areas of identified need providing a clear induction and development pathway to newly appointed managers 60% of questionnaire respondents reported that they had referred to the Directory in planning development discussions or appraisals of the staff that they manage. Having a list of the courses available, how and where you access them, and having it divided into the three sections proved useful in identifying appropriate training. 4) Supporting teams to improve people management competencies and develop departmental training plans There were examples of senior managers adopting the Directory within their overall succession planning programmes. The Directory provided a means by which staff could begin to explore the learning available within the area of people management as part of reviewing their own career aspirations and whether they may wish to aspire to a managerial role in future. The Directory was also used in one area to inform departmental training plans. This an example of good practice that could inform the future development of workforce planning processes. The Directory may also be a beneficial tool to be considered in developing team action plans, for example to reflect imatter outcomes in relation to training and development. imatter contains specific questions which link to the Staff Governance Standard strand Appropriately Trained and Developed. Teams who feel this element is having a negative impact on their experience at work may choose to develop appropriate actions to address this in their team action plan. The Directory will help inform the action planning by enabling the identification of appropriate learning and development. The NHS Tayside imatter Board Report 2016, demonstrates that scoring against the statement I am given the time and resources to support my learning growth is the lowest of all those in the section Experience as an Individual. It is anticipated that the Directory will help improve this metric. 5) Improved frequency of appropriate training access The Directory was reported as having prompted managers to consider the time and resource that they were making available to their teams to source and attend training and development. 60% of questionnaire respondents reported that they had been given protected time to access the Directory and/or undertake training. 20% of the 56 users in Specialist Services are known to have booked into HR&OD face to face training during the pilot phase whilst 40% reported that they had booked into more than 3 courses/programmes including learnpro. The Directory is recognised as being a catalyst for increased demand. Directory as a live document To ensure the Directory was both meaningful and current for staff it was important that the pilot version was effectively administered and updated regularly. This meant ensuring the programmes and training available was regularly updated and modified. 3

147 4. IMPLEMENTATION OF PHASE 2 RECOMMENDATIONS The People Management Learning Directory oversight group request that the Committee consider the following recommendations. Implementation of Phase 2 of the Directory through graduated roll out, initially to pro active Directorates, a willing coalition of supporters. Development of the Directory within an e-platform that is a reflection of the quality and value we place on our People Development. Aligning of the Directory with similar and compatible work in the area of management development, eg Health and Safety, Statutory and Mandatory etc. Continued monitoring of the roll out via the oversight group. The group will consider ways we can continuously improve the Directory based on feedback from staff. 5. REPORT SIGN OFF David McFarlane Associate HR Business Lead Sharon Slane Organisational Development Consultant 4

148 Pilot Version 2016/1 (last updated 19/01/2017) Appendix 1 People Management Learning Directory Name Job Title Manager s Name. 1

149 NHS Tayside People Management Learning Directory Introduction The People Management Learning Directory is applicable to all supervisors and line managers. It is available in paper format and electronically on Staffnet. Updates to the Directory will be made electronically. The hyperlinks to learning resources may lead to log on pages that require registration to another site. Aim The aim of this document is to inform you of the learning opportunities that are available within NHS Tayside within the area of People Management. This will support you in planning career and personal development and also help ensure that supervisors and managers are competent to undertake people management tasks/roles The Directory captures broad topic areas of People Management and these are aligned with recognised core competencies including e-ksf. Within the topic areas 3 learning levels are identified. The learning interventions that are available within NHS Tayside are mapped within these topic areas and learning levels. Learning levels are explained below. Application Supervisors/Managers should discuss their training and personal development with their line manager as part of their personal development planning. It needs to be determined which level will be most suitable for the learner based on their job function and / or management level. This Directory is a guide to learning interventions and individual learning will be developed further when supervisors/managers are supported to apply skills in practice. The Directory may be updated with new learning opportunities. Successful learning at any given level does not require the learner to complete all of the courses available but rather to have achieved competency within the learning level as described below. All training should be recorded on eksf or Team Domino. Professional Development The People Management Learning Directory is designed to compliment, and does not replace, any CPD requirements of the professions or any leadership/management programmes provided by NHS Tayside to specific types of professionals. 2

150 People Management Learning Directory Overview Learning Level 3 Organisational Change & Staff Engagement Management Policies Learning level 2 Recruitment Organisational Change & Staff Engagement Management Policies Employee Health and Wellbeing & Work Life Balance Learning Level 1 Recruitment Equality and Diversity Management Policies 3

151 Learning Levels explained Introduction The framework of learning levels is designed to provide a staged approached to learning with level 1 learning providing the key knowledge that will underpin skills based learning of level 2 and finally to level 3. In general each level corresponds to the responsibilities for supervision and management of employees. Firstly it needs to be determined which level will be most suitable for the learner based on their job function and / or management level. This can be either the level that they work at now, or a level they wish to aspire to.. Learning Level 1 - Learning within Level 1 will provide general awareness and knowledge that should be achieved and maintained by managers at all levels. Level 1 will provide the key learning for all first line managers/supervisors who have responsibility for day to day supervision and monitoring of staff. This will include work allocation, checking and evaluating work, providing training to staff, undertaking work assessments and implementing local improvement initiatives. Level 1 knowledge will be key for those who have responsibility for initial informal stages of grievance, discipline, sickness absence, reviewing work performance and progress. Delivery will typically be through e-learning and awareness sessions. Learning Level 2 Experienced managers and supervisors who have day to day management responsibilities and a wider span of control than a first line manager. Will hold some leadership responsibility and will propose and implement necessary developments and changes within their department. Will have decision making responsibilities in relation to all or most of the following: sickness absence; disciplinary and grievance matters; performance management, recruitment and selection decisions; personal and career development of staff; departmental workload and allocation. Learning within Level 2 will provide intermediate to advanced skill development. The learner will have an existing knowledge as delivered within Level 1. Delivery will typically be through workshop sessions delivered by specialists in the field. Learning Level 3 Senior managers who will have people management responsibilities that involve complex facts or situations, which require the analysis, interpretation and comparison of a range of options. This will include decision making responsibilities for most of the following; the management of strategic change; investigating, assessing and reviewing complex cases relating to; sickness absence; disciplinary and grievance matters; performance management. Learning within Level 3 will provide stretch experience and advanced learning to managers with an existing knowledge and skills set as delivered within Levels 1 & 2. Delivery will be by experts in the field and will include events and workshops provided by both in-house experts and external experts. Each of the topic areas corresponds to e-ksf core dimensions and will support personal development of supervisors and managers within these dimensions Linked e-ksf Dimensions 4

152 Level 1 - Recruitment Course Provider Time Overview Date of learning Recruitment and Selection Module Learnpro e-learning This module will help managers gain an understanding of the Recruitment and Selection Policy and the processes of recruitment Outcomes achieved Signature Learn Pro Programmes/Managers Induction Programme/7 HR Level 1 Equality and Diversity Course Provider Time Overview Date of learning Equality and Diversity Foundation Module Learn Pro e-learning This module should help you to understand relevant equality legislation and policy frameworks. It was developed to show the link between equality, diversity and good working practice Outcomes achieved Signature Learn Pro Statutory/Mandatory/Equality and Diversity Foundation 5

153 Level 1 - Management Policies Course Provider Time Overview Date of learning NHS Tayside, HR Managers modules Learnpro e-learning This e-module will help managers gain understanding of following policy areas Management of Capability Promoting Attendance At Work Grievance Policy Employee Conduct Outcomes achieved Signature Learn Pro Programmes/Managers Induction Programme/7 HR/ Promoting Attendance at Work Policy HR Business Team 40 minutes Awareness session developed in partnership by the Policy Group covering the key aspects of this policy NHST Training Database Search Training Database under Search Courses select Learning and Development Centres (Dept) and select the required session Policy Awareness HR Business Team 40 minutes Awareness sessions developed in Partnership by the Policy Groups in key Management Policy areas: Conduct 6

154 Capability Grievance Preventing and Dealing with Bullying and Harassment Fixed Term Contract Policy NHST Training Database Search Training Database under Search Courses select Learning and Development Centres (Dept) and select the required session Introduction to Team Leader Course Policy awareness sessions are also delivered as one of the component modules of the Introduction to Team Leader Course in the following policy areas Management of Capability Promoting Attendance At Work Grievance Policy Employee Conduct Introduction to Team Leader 7

155 Level 2 Recruitment Course Provider Time Overview Date of learning Certificate to Recruit Learning and Development Team 3 hours Are you a manager involved in the recruitment of new staff? Are you developing your role within NHST and may be recruiting staff in the future? NHS Tayside aims to be an exemplar employer and Certificate to Recruit helps you achieve this by exploring our Public Sector Duty with close regard for the Equality Act Outcomes achieved Signature NHST Training Database Search Training Database under Search Courses select Equality and Diversity (Dept) and select the required course Level 2 Organisational Change & Staff Engagement Course Provider Time Overview Date of learning Managing Change in NHS Tayside HR Business Team 1 hour This workshop will support managers to develop their understanding of the key steps to implementing successful change within NHS Tayside s policy framework and the importance of staff engagement during periods of change. NHST Training Database Search Training Database under Outcomes achieved Signature 8

156 Workforce Planning Training 6 Steps Methodology HR Department - Workforce Planning Services Search Courses select Learning and Development Centres (Dept) and select the required workshop 2.5 hrs This workshop will support managers to understand the methodology and process of workforce planning Through interactive elements participants will begin to develop a Workforce Plan NHST Training Database Search Training Database under Search Courses select Learning and Development Centres (Dept) and select the required workshop Additional Contact Information Courageous Conversations Organisational Development Team 3 hours Having the skill, confidence and resilience to initiate and follow through on courageous conversations is a key leadership responsibility. Many of us imagine that the success of a courageous conversation is our ability to manage the meeting itself, however, the truth is that it s all in the preparation. Courageous Conversations Values Based Leadership 3.5 hours Values Based Leadership is designed 9

157 Leadership and Management Team to help anyone become a leader - that is, a leader who contributes to the fulfilment of important values... values like trust and respect, dignity and cooperation, caring and service. Values Based Leadership Building Effective Working Relationships Organisational Development Team 3 hours Challenging Difficult Behaviours Today's working environment depends very much on relationships. It is rare that you can be effective without working with others. Understanding different approaches people take can make you more effective and support you to build relationships. Having Caring yet Courageous Conversations Having the courage and reach out to another person and talk to them about the things that matter most to you. Having the skill, confidence and resilience to initiate and follow through on caring yet courageous conversations is a key leadership responsibility. Developing and Building Effective Working Relationships 10

158 Level 2 - Management Policies Course Provider Time Overview Date of learning Outcomes achieved Signature NHS Scotland Counter Fraud Services Learn pro e-learning The purpose of this training is to raise your awareness and understanding of fraud within Scotland's NHS Your participation in the programme will raise your awareness of fraud within the health service in Scotland provide you with an overview of its impact and show you the role you can play to protect NHS resources. Learn Pro Mandatory/NHS Scotland Counter Fraud Services Management Policies - Workshops HR Business Team Skills based workshops tailor made to departmental requirements focussing on competencies required of managers responsible for implementing policies and that is not otherwise covered within the Directory. Designed to support improvement work that departments and management teams are focussing on HR Business Team 11

159 Investigations and Presenting a Case HR Business Team 2 hours This workshop is designed to support managers who have responsibilities for conducting employee conduct investigations and presenting a case to a Disciplinary Hearing Employee Conduct Policy Training Dates Level 2 - Employee Health and Wellbeing & Supporting Work Life Balance Course Provider Time Overview Date of learning Flexible Working Requests HR Business Team 40 minutes Workshop designed to provide managers with an understanding of Flexible Working Requests including the legal framework and responsibilities of managers in handling such requests Outcomes achieved Signature Drug and Alcohol Problems in the Healthy Working Lives NHST Training Database Search Training Database under Search Courses select Learning and Development Centres (Dept) and select the required workshop 3 hours This workshop is designed for managers, Team Leaders and Supervisors who want to know more and have an effective way of dealing with alcohol and drug problems in the 12

160 Workplace workplace Mentally Healthy Workplace Training for Managers and Supervisors Health Working Lives Full Day Drug and Alcohol Problems in the Workplace The Mentally Healthy Workplace Training programme has been developed by the Scottish Centre for Healthy Working Lives in partnership with the Scottish Development Centre for Mental Health. It is designed to encourage good practice in promoting positive mental health and well being. It aims to: Give employers and line managers a broad understanding of mental health. Managers Training Stress Management Competencies Healthy Working Lives 3 hours Mentally Healthy Workplace Training This 3 hour intensive workshop provides participants with an overview of the Stress Management Competencies and an insight into the tools available to them. The competencies were developed by the HSE and CIPD to support line managers to develop effective management practice that minimizes the risk of stress. Resilience and Wellbeing Workshop Healthy Working Lives 3 hours Stress Management Competencies Workshop This workshop is designed for Managers, Team Leaders, Supervisors who are committed to creating a mentally healthy workplace This will provide you with the knowledge and tools to build employee resilience to help employees perform well and stay well Resilience Training

161 Level 3 Organisational Change & Staff Engagement Course Provider Time Overview Date of learning Resilience for Leaders Leadership and Management Team 3.5 hours Resilience the capacity to bounce back from setbacks or to thrive during times of challenge or change is not a fixed trait. It actually grows out of a set of learnable behaviours with results that interact to make you and your team less vulnerable to stress. Whether you re dealing with the acute stress of sudden challenges, or the chronic stress of daily life, simple daily actions can increase your resilience. Outcomes achieved Signature Resilience for Leaders Performance Management Leadership and Management Team 3.5 hours Performance Management is about understanding each other, the service and standards of care we provide to our patients and customers. If you are a supervisor or a manager and want to lead a happy, productive and successful team you are invited to enrol on this half day course. Performance Management 14

162 Level 3 Management Policies Course Provider Time Overview Date of learning CLO Training Central Legal Office Employment Team Full day The CLO, NHS National Services Scotland, deliver practical seminars focussing on difficult and complex workplace issues. Details of scheduled seminars will be posted [here]. Outcomes achieved Signature Chairing a Disciplinary Hearing or Appeal Hearing HR Business Team 2 hours This workshop is designed to support managers who have responsibilities for chairing Disciplinary Hearings and Appeal Hearings. Attending a Tribunal HR Business Team Employee Conduct Policy Training Dates 1 hour This workshop will provide an understanding of the tribunal process including the role of the CLO, HR and witnesses. This workshop will be of particular benefit to managers and staff who are required to attend a tribunal and will support their preparations. This workshop is scheduled on a request basis Attending a Tribunal 15

163 Further Resources Other opportunities and learning programmes which may be beneficial at any level include: Coaching Coaching builds a relationship based on respect and the notion that people have the solution to their own problems. Coaching supports people to access these hidden resources in the service of the team or organisation. A coaching style can contribute to the development of a healthy organisational culture, through development of skills such as direct communication and respectful challenge. The Tayside Public Sector Coaching Alliance facilitates Introduction to Coaching workshops for further details please contact Fiona Young at fyoung4@nhs.net Values Based Reflective Practice - Values-based Reflective Practice is an intentional way of reflecting on past practice in the present in order to improve practice in the future. VBRP promotes person-centred care, engages in dialogue between personal and organisational values, attitudes and behaviours, enhances staff experience and turns history (what we have done) into learning. Information regarding this training course can be accessed here Appropriate for Level 2 and 3 Paired Learning - The peer learning leadership development initiative Paired Learning is designed to pair-up different healthcare professionals & managers to provide the opportunity for them to learn from each other s experiences and expertise in developing and improving services for patients. Paired Learning is currently being piloted in NHS Tayside - for further information contact Kathleen Paterson at kpaterson4@nhs.net Supporting the Current - is about aiding those individuals already in a leadership or management posts, building on their experience and supporting them in their continuing professional development as a manager/leader. A number of assessments are available: o MBTI (Myers-Briggs Type Indicator) questionnaire o 16PF questionnaire o Strength Deployment Inventory Tool (SDI) o Bar-On EQ-I - Emotional Quotient Inventory (EQ-i ) o 360 Feedback Tool Further details can be found here or contact Nicola Ogilvie, Leadership and Management Team at nogilvie@nhs.net 16

164 Building the New extended learning programmes are available to support the ongoing development of managers: Action Centred Leadership - The aim of this programme is to give each participant the opportunity to understand the nature and practice of good leadership in such a way as to make you more effective as a leader, colleague and team member Course duration: 2 days Further details can be found here or contact Nicola Ogilvie, Leadership and Management Team at nogilvie@nhs.net SVQ Level 3 in Leadership The qualification aims to give participants an opportunity to develop their management performance, become more effective and to progress their career. Participants take four mandatory units (which look at managing resources, health and safety, leadership, and allocating/monitoring work) plus three optional units. The wide choice of optional units gives a high level of flexibility, allowing the qualification to be tailored to meet the varying needs of participants and employers across all employment sectors. Course duration: 6-9 months Further details by contacting Nicola Ogilvie, Leadership and Management Team at nogilvie@nhs.net ILM level 3 Certificate in Leadership & Management This is ideal for individuals who have management responsibilities but no formal training, and are serious about developing their abilities. They particularly support practising team leaders seeking to move up to the next level of management, and managers who need to lead people though organisational change, budget cuts or other pressures. Course duration: 6 months Further details by contacting Nicola Ogilvie. Leadership and Management Team at nogilvie@nhs.net Adaptive Leadership - Based on the very successful programme held previously we are running another adaptive leadership programme, a development based predominately on the Adaptive Leadership Models of Heifetz. The emerging model of the programme is: Contributing to Leadership rather than being leader Getting to grips with an Adaptive problem (questions not answers) Building shared purpose, contribution, ownership of the issues Filling the gap when needed and encouraging other to fill it with the contribution that is needed at the time Anyone from anywhere in the hierarchy Course duration: 6 days Further details by contacting Nicola Ogilvie. Leadership and Management Team at nogilvie@nhs.net 17

165 Action Learning Sets- Potential for development, opportunity for leaders to network and share current work issues Under development Assertiveness Skills - This course is designed to equip managers to deal assertively with situations at work, and to achieve win/win results every time. Participants will be encouraged to identify their preferred style of communication and to explore the effectiveness of their approach Course duration: ½ day Assertiveness Skills Presentation Skills Are you an existing Supervisor/Manager preparing for that all-important presentation or interview? Is there a requirement for you to start presenting data/information to selected audiences? Are you already delivering presentations but would like some formal training and feedback? Course duration: 1 ½ days Presentation Skills 18

166 Item 9.6 Appendix 2 Focus Group A focus group was held 06 February 2017 with members from the pilot group. The feedback and key points captured during the discussion is detailed below. Benefits of the Directory Having the information in one place Easy to access Using it as a resource/aid to discussions during 1:1 PDR/PDPs and supporting eksf conversations It provides a focussed resource, as it tended to be a stab in the dark before!! Increased an awareness of what training and resources are available Increased an awareness of organisational systems Increased understanding of what s statutory/mandatory requirements for staff Proactive use of the directory for succession/workforce planning and identifying potential future managers, by inviting colleagues to participate in it if keen to do so Potential Areas for Further Development For newly appointed manager/team leader/supervisor role, opportunity to align the directory with period of induction and make a direct link with the NHS Tayside Induction Policy Opportunity to improve easy access, reduce number of clicks Identifying the most obvious locations on Staffnet for this resource to sit e.g. under HR? Under policies? Under Learning & Development? (under them all!) Develop a summary sheet at the beginning of the directory Layout e.g. a z? To develop a system of alerts of any new relevant policies or changes made (e.g. to RAFs)?links to the Policy Tracker Tool system Links to LearnPro system/relevant modules Key Messages Important to ensure a standard quality training experience every time, as positive feedback will reinforce benefits/value of the directory Can align recording of training activity into PDR/P, eksf system Need to sell it An inclusive approach to the Directory s use e.g. medical staff s direct involvement and use of it will be important to promote benefits to clinical/medical managers Model of roll out and extending the directory s use important to think about where it would sit on Staffnet. A clear pathway to find it is needed!! Discussion regarding the title of the directory -?the use of the word management important that it is clear available to all staff Potential visual ideas for promoting the directory, for example using a hub and spoke model

167 Questionnaire Feedback has also been gained from the pilot groups through use of questionnaire. Response Rate 29 % Were you given protected time to access the Directory and/or undertake training? 60% How many times have you opened and viewed the Directory? % % >10 20% Did the Directory make you aware of any learning opportunities that you wouldn t have Yes 60% otherwise known about? How many programmes/courses have you booked into via the Directory? 1 40% 2 20% 3 40% Have you referred to the Directory in planning any development discussions or appraisals for the Yes 60% staff that you manage? How useful was the Directory (1 not useful, 5 helpful, 10 very helpful) 8 Free text questions Identified benefits Easy to use It was useful to find out what was in it so that it could be recommended to other staff members. It was a good refresher for myself made me more aware of the trust policies The cope of training provided by NHS Tayside. This helped me when writing our management training logs having a list of the courses available, how and where you acces them, and having it divided into three sections felt that it was a one stop shop for training opportunities Areas for development having more time to do it some short video clips [learnpro] to illustrate the points being made unable to book on some of the courses as no dates available I think there should be something about NHST systems eg SSTS, but I am not sure if it fits here it s difficult to navigate learnpro some of the courses do not have dates tie in to NHS Leadership programme Trainee numbers Face to Face training delivered by HR & OD Directorate Specialist Services Pilot participants booking in to HR&OD Face to Face Training from 01 July to 31 December % (11/56) July 2016 HR&OD Face to Face represents 61% of Directory content (19/31) January 2017 HR&OD Face to Face represents 54% of Directory content (13/24)

168 Please note any items relating to Committee business are embargoed and should not be made public until after the meeting Item 10.1 SGC/2017/14 Staff Governance Committee 14 March 2017 Terms of Reference Staff Governance Committee Author: George Doherty Review Group: Staff Governance Committee Review Date: September 2016 Last Update: December 2016 UNCONTROLLED WHEN PRINTED Signed: George Doherty Director of Human Resources

169 STAFF GOVERNANCE COMMITTEE TERMS OF REFERENCE AND WORKPLAN Executive Lead The Executive Lead Officer for this Committee is the Director of Human Resources, NHS Tayside 2. Support Officer Items for the agenda should be submitted to the Committee Administration Officer, Mrs Nicki Owen, who can be contacted at Ninewells Hospital, Dundee, DD1 9SY, telephone , extension or by 3. Purpose 3.1 The purpose of the Staff Governance Committee is to provide assurance to the Board that NHS Tayside meets its obligations in relation to staff governance under the National Health Service Reform (Scotland) Act 2004 and the Staff Governance Standard. 3.2 In particular, the Committee will seek to ensure that staff governance mechanisms are in place that take responsibility for performance against the Staff Governance Standard and are accountable for progress towards achievement of the Standard. 3.3 The Staff Governance Committee will also play a key role in monitoring overall Board performance by ensuring full consideration of the impact of key policy and operational decisions that affect staff, on the Board aims in relation to quality and cost of service delivery. 4. Composition 4.1 The Board shall nominate six Non-Executive Directors of the NHS Board to be members of the Committee including the Chair of the Board and the Employee Director. The Committee will be co-chaired by the Employee Director and a Non-Executive Director appointed by the Board from the membership of the Committee. The Lead Officer, Director of Human Resources and Organisational Development will also be a member of the Committee. 4.2 Members of the Area Partnership Forum listed below shall be ex-officio Members of the Committee (without voting rights): Chief Executive Chief Officer (representing Health and Social Care Partnerships) Chief Operating Officer Area Partnership Forum Staff Side Secretaries (2) Co Chairs of other Partnership Forums The Committee may invite to attend other senior managers and trade union representatives. 5. Meetings 5.1 There should be four meetings per annum with provision for additional meetings as required. 2

170 5.2 Five Members of the Committee, at least 3 of whom should be Non-Executive Directors must be present in order to form a quorum. 5.3 The minutes of the meetings will be submitted to the NHS Board. The Joint Chairs of the Committee will also make a formal report to the Board on a regular basis, at least annually, covering the activities of the Committee and any significant matters of note. 6. Remit 6.1 The Committee shall support the creation of a culture within the health system, where the delivery of the highest possible standards of staff management is understood to be the responsibility of everyone working within NHS Tayside and this is built upon partnership and co-operation. 6.2 The Committee shall act for the Board in ensuring that structures and processes to ensure staff are: Well informed; Appropriately trained and developed; Involved in decisions; Treated fairly and consistently, with dignity and respect, in an environment where diversity is valued; and, Provided with a continuously improving and safe working environment, promoting the health and wellbeing of staff, patients and the wider community. 6.3 The Committee shall monitor and evaluate progress through the approval of local human resource strategies and implementation plans. 6.4 The Committee shall be authorised by the Board to support any policy amendment, funding or resource submission to achieve the Staff Governance Standard. 6.5 The Committee shall oversee the timely submission of all the staff governance data required as part of the Annual Review. 7. Joint Working with Other Board Committees 7.1 The Committee shall ensure the implications of workforce performance are fully understood and that all decisions taken relating to staff are subject to appropriate scrutiny in relation to quality and cost of service delivery. In doing so the Committee will share information with, and receive information from, the Board's Finance & Resources Committee and the Clinical Care Governance Committee, and lead officers of these Committees will meet jointly on at least two occasions per year to review performance and agree priorities for future reporting. 7.2 The Committee will, through its lead officers, also regularly consider key issues arising through other Committees of the Board to ensure that relevant information is shared to aid understanding of workforce strategic and operational performance matters. 8. Risk Reporting Quarterly reports from strategic risk owners of the risks aligned to this Committee. 9. Best Value The Committee is responsible for reviewing those aspects of the Best Value work plan which are delegated to it from Tayside NHS Board. The Committee will put in place arrangements which will provide assurance to the Chief Executive as Accountable 3

171 Officer, that NHS Tayside has systems and processes in place to secure the best value for these delegated areas. The assurance to the Chief Executive should be included as an explicit statement in the Committee s Annual Report. 10. Authority The Committee is authorised by the Board to investigate any activity within its terms of reference, and in so doing, is authorised to seek any information it requires from any employee. 11. Reporting Arrangements 11.1 The Staff Governance Committee reports to Tayside NHS Board Following a meeting of the Staff Governance Committee, the minutes of that meeting should be presented at the next Tayside NHS Board meeting The Staff Governance Committee should annually and within three months of the start of the financial year provide a work plan detailing the work to be taken forward by the Staff Governance Committee The Staff Governance Committee will produce an Annual Report for presentation to the Audit Committee. The Annual Report will describe the outcomes from the Committee during the year and provide an assurance to the Audit Committee that the Committee has met its remit during the year. The Annual Report must be approved by the Staff Governance Committee before it is presented to the Audit Committee The Staff Governance Committee will receive for approval the Annual Report of the Remuneration Committee, which reports through the Staff Governance Committee to the Board, while remaining a substantive standing Committee of the Board itself The Committee shall oversee the effectiveness of the Area Partnership Forum, and through the Area Partnership Forum, the performance of Local Partnership Fora, in managing change and promoting a positive culture of staff engagement through the submission of regular reports. 12. Reporting Schedule See Appendix 1 4

172 Appendix 1 STAFF GOVERNANCE COMMITTEE Best Value Workplan 2016/17 This workplan outlines the major items the Staff Governance Committee has to consider as part of its schedule of work and the corresponding Best Value Characteristics under the headings of regular reports, annual reports, corporate risk reporting, minutes for information and policies

173 STAFF GOVERNANCE COMMITTEE WORKPLAN 2015/16 Responsible Officer Best Value Characteristics 21 June September December March 2017 Regular reports submitted to the Committee Involved in Decisions which Affect Them Judith Golden/ Alan Small Performance Management Appropriately Trained Pat Millar Performance Management Deferred until Dec 16 X Safe and Improved Working Environment Lorna Wiggan Performance Management Well Informed Margaret Dunning/ Jane Duncan Performance Management Deferred until March 17 Treated Fairly and Consistently Christopher Smiyth Performance Management X Cross Cutting Theme -Equality 2020 Workforce Vision George Doherty Performance Management X Monitoring Reports Workforce Information (including Medical Staffing) Promoting Attendance at Work Recruitment Activity Jennifer Mudie Christopher Smith/Ian McEachan Jennifer Mudie/ Val Beattie Annual Report/Q4 Annual Report/Q4 Annual Report/Q4 Q1 Q1 Q1 Q2 Q2 Q2 X Q3 X Q3 X Q3 6

174 STAFF GOVERNANCE COMMITTEE WORKPLAN 2015/16 Responsible Officer Best Value Characteristics 21 June September December March 2017 Staff Governance Monitoring Report (formerly SAAT) NHS Tayside Health Working Lives, Health, Safety and Well being Daniel Courtney Pat Davidson X X imatter Update Lucy Archer X X X Healthcare Academy Alison Smith X Valuing People Valuing Personal Development Plans (PDPs) Jenni Jones/Pat Millar Whistleblowing Alison Rogers Annual Reports Annual Reports that are reported to the Committee Staff Governance Annual Report George Doherty X Staff Governance Terms of Reference George Doherty Healthcare Academy Alison Smith Cross Cutting Theme - Sustainability Remuneration Committee Annual Report George Doherty Partnership Annual Report George Doherty/ Judith Golden Equality & Diversity Workplan C Smith Cross Cutting Theme - Equality X 7

175 STAFF GOVERNANCE COMMITTEE WORKPLAN 2015/16 Responsible Officer Best Value Characteristics 21 June September December March 2017 Workforce Plan Jennifer Mudie OHSAS Annual Report Christopher Smith OHSAS no longer in existence Update Report Recieved Consultant Appraisals Annual Report Andrew Russell Use of Resources X GP Appraisal Annual Report Andrew Russell Use of Resources X Health & Safety Annual Report Lorna Wiggan/ Ken Armstrong Deferred until Dec 16 Deferred to March 17 Corporate Risk reporting risks aligned to the Committee Medical Workforce (Risk Ref 95) Workforce Efficiencies Risk Ref 58) Nursing Workforce (Risk Ref Annual Mid Year Assurance Report Andrew Russell Jennifer Mudie Eileen McKenna Report not received Sept 16 Dec 16 X X X Minutes for information Minute to be presented as soon as practicable Area Partnership Forum Minutes Susan Graham 26 Jan 2016/ 23 Mar May 2016/ 27 July 2016/ 21 Sept Nov Jan 2016 Joint Negotiating Committee Minutes Lorraine Smith 6 April June 2016 Meeting Cancelled Workforce & Governance Forum Minutes Susan Graham 6 Jan 2016 Meeting Cancelled 2 Mar 2016/ 4 May Jul 2016 meeting cancelled / 24 Aug Oct 2016/ 14 Dec Nov 2016/ 11 Jan

176 STAFF GOVERNANCE COMMITTEE WORKPLAN 2015/16 Responsible Officer Best Value Characteristics 21 June September December March 2017 Policies to be endorsed by the Board as and when required Facilities & time off For Trade Union Duties Bank Policy Breastfeeding & Returning to Work Paternity & Parental Employee Conduct Whistle Blowing Policy Smoking Policy Skills Register Fixed term Contract Induction & Orientation 9

177 Item 10.2 Please note any items relating to Staff Governance business are embargoed and should not be made public until after the meeting SGC/2017/15 Staff Governance Committee 14 March 2017 EMPLOYABILITY SERVICES 1. SITUATION AND BACKGROUND NHS Tayside Employability Services is located within Human Resources and Organisational Development and provides an Annual Report that is submitted to NHS Tayside Staff Governance Committee. The report outlines work concerning delivery of skills and training for people within Tayside presently experiencing barriers to work. The overall aim is to promote positive outcomes such as employment, preferably within the care sector, further education or relevant training. A crucial element of the work of Employability Services is in providing work experience for people who have been out of work, or who are unused to the workplace and its requirements and challenges. In addition to providing career opportunities, this work is delivered against a background of research which reinforces employment and career progression as a key element of both individual and community health. The report will also highlight and acknowledge the statutory and non statutory partnerships required to implement and to continue to develop programmes concerned with employability against a background of welfare reform and health and social care integration. 2. ASSESSMENT Over the past year, Employability Services has continued to work with a range of partners including local colleges and councils, Skills Development Scotland and the Department of Work and Pensions to provide opportunities for people to access relevant work experience or training opportunities. Employability Services has clear, governance based guidelines for each programme delivered based around Codes of Conduct, Health and Safety, Occupational Health and Disclosure as required. Participants who successfully complete indentified programmes are given access to guaranteed interviews for essential support services within NHS Tayside for a period of 6 months following completion Established programmes using the academy model at both certification and qualification level have continued to be delivered across Tayside. The programmes vary in length from 6 to 32 weeks. Employability Services has been closely involved in the review of Employability in Dundee City, and engaged with the Employability Network in Perth and Kinross. Employability Services has worked closely with Developing the Young Workforce in Dundee and Angus to provide information around potential careers and services for young people. Work experience placements for young people between the ages of have been provided across the organisation involving training partners such as Barnardos and HELM and local councils. Funding is supplied through Skills Development Scotland, and administered through the training partner. 1

178 There has been increased interaction with community based groups within the region, with information sessions provided around career pathways within the NHS and to enhance awareness of NHS Tayside as a service and potential employer. Employability Services has continued to work at national level with NHS Education for Scotland and the Scottish Government with particular reference to Health Care Support Workers Development and development of the Business and Administration Career Framework. Health Care Support Workers Induction Standards continue to show compliance at 90+% overall with increased in house delivery of the Codes of Conduct. Specific clinical and non clinical areas have indicated willingness to engage in developing Code Champions to embed the Codes which reflect the Aims, Vision and values of NHS Tayside. This will be an ongoing process. Changes in funding processes at local and national levels, especially with the challenges attendant on Welfare Reform and Health and Social Care Integration have reinforced the importance of partnership working on all levels; therefore Employability Services will require to maintain its established and robust partnership working with agencies across statutory and non statutory services to ensure that relevant support continues to be provided to people experiencing barriers to work and to provide them with skills to access future careers or signpost relevant training or education. 3. RECOMMENDATIONS The Staff Governance Committee is asked to approve the attached NHS Tayside Employability Services Annual report , incorporating the work plan for REPORT SIGN OFF Alison Smith HR Lead: Employability Services 06/03/2017 Ms L McLay or Name of Lead Officer Chief Executive or Designation of Lead Officer 2

179 Item 10.2 Appendix 1 ANNUAL REPORT NHS Tayside Employability Services

180 CONTENTS PAGE(S) FOREWORD SUMMARY NATIONAL DRIVERS INFLUENCING NHS TAYSIDE EMPLOYABILITY SERVICES... 4 Activity Summary Employability Programmes... 5 Young Peoples Agenda... 5 Public Engagement... 5 Health Care Support Workers NHS TAYSIDE EMPLOYABILITY SERVICES ACTIVITY... 6 EMPLOYABILITY SERVICES STANDARD PROCESSESS EMPLOYABILITY PROGRAMMES Pre Employment Programmes Qualification Based Programmes Young People COMMUNITY LAISON...13 WELFARE REFORM HEALTH CARE SUPPORT WORKER INDUCTION STANDARDSAND CODES OF CONDUCT NATIONAL INITIATIVES 14 NHS TAYSIDE EMPLOYABILITY SERVICES OBJECTIVES AND PROPOSED DEVELOPMENT FOR APPENDICES REFERERENCE

181 FOREWORD: NHS TAYSIDE EMPLOYABILITY SERVICES ANNUAL REPORT It is my pleasure to formally introduce the NHS Tayside Annual Report for Employability Services The department has again delivered key employability programmes and initiatives to support individuals within the community to gain the skills, confidence and opportunities to seek and sustain sustainable job outcomes. I am pleased that the pre-employment programmes that were delivered across Tayside for people experiencing joblessness were able to report 64% job outcomes for those completing the course as of (56 individuals) and within the current year for those tracked to date this is at 58% (33 individuals) with many of these individuals gaining employment within the NHS. The clinical qualification based programme outcomes are recorded one year in arrears, and for those who successfully completed the full SVQ2 in Social Work and Health in the job outcome rate was at 83% (20 individuals) with 2 individuals who failed to gain employment opting to return to Further Education NHS Tayside is the largest employer within the local area and it is good to see an organisational commitment to programmes to support individuals within the community experiencing joblessness and difficulties in securing employment, as a key social responsibility. More than the data, what provides me most satisfaction is stories such as that of Courtney, Anna, Jennifer and Karen within this report, demonstrating the positive impact the department makes in assisting individuals to secure employment, particularly those that have experienced obstacles and setbacks in their working life. It is good to see more partnership work was undertaken this year and I would look for this to continue as we are unable to deliver any of these outcomes for the community without the support and assistance of key partners such as Jobcentre Plus, Skills Development Scotland and the local colleges and voluntary and independent sector agencies supporting employability in the community The report also makes reference to policy challenges and barriers faced in supporting more people into employment, such as opportunities available for young people over the age of nineteen, rural challenges, referrals from key sources and funding challenges, policy challenges that the department should actively work with partners to reduce or resolve. It is good to see that the department is fully engaged in key agendas such as Welfare Reform, Young Peoples Employability Agenda and also Health & Social Care Integration, increasing awareness of the department and increasing opportunities for those undertaking our programmes. Whilst there has been some good work in increasing community liaison and public engagement by the department to promote opportunities within NHS Tayside, it is envisaged that this will increase over to ensure greater engagement with key communities and promote NHS Tayside as an employer of choice. I would like to thank the Employability Services Steering Group consisting of key partners and in particular Alison Smith and Joan Laing for all their work in delivering the programmes, working in partnership and supporting and assisting jobseekers. Munwar Hussain 1

182 Chair of Employability Services Steering Group SUMMARY NHS Tayside works in close partnership across the region with both statutory and non statutory services to provide strong and sustained support for people of all ages experiencing barriers to employment. Building on the commitment made by NHS Tayside Board in 2006, NHS Tayside provides a focus on social inclusion and socially responsible recruitment through Employability Services, located in Human Resources and responsible to the Associate Director of Human Resources Resourcing Employability Services adheres at all times to NHS Tayside s Aims, Vision and Values, and achieves its success through strong partnership working with colleagues across NHS Tayside and with external partners. A tenet of the service is to maintain good Governance on all practise at all times. PARTNERSHIP Partners committed to the employability process and supporting the health and well being of local communities include the Department of Work and Pensions, Skills Development Scotland, Dundee & Angus College, Perth College: UHI, Angus, Dundee and Perth & Kinross Councils, and representatives of the independent and voluntary sectors: In these partners have included:- Barnardos Rathbone Craigowl Communities Gowrie Care ACTIVITY SUMMARY Employability Programmes Seven pre employment programmes were delivered across Tayside funded through the Department of Work and Pensions and Skills Development Scotland. These short courses are targeted at people experiencing joblessness One 32 week course delivered via Dundee & Angus College leading to an SVQ 2 in Social Work and Health One 32 week course delivered via Dundee & Angus College leading to an SVQ2 in Business & Administration Young Peoples Agenda Working with third sector partners to deliver 13 week work experience programmes for young people between years who access Skills Development Scotland Employability Fund Partnership with Dundee City Council to support the NHS Tayside Looked After Young people programme through identifying work experience placements Investigating the feasibility of a Princes Trust Get into Care course in NHS Tayside Public Engagement Continuing to engage with NHS Tayside Welfare Reform Group to inform employability programmes and support multi agency Welfare Reform activities Working with Department of Work and Pensions to access work experience opportunities for people with barriers to work and positive destinations 2

183 Engaging with community based organisations to develop greater awareness of career prospects and structure within NHS Tayside and the wider care sector. Health Care Support Workers Ensuring required support and guidance for staff around compliance with HCSW Induction Standards and Codes of Conduct. Maintaining a robust recording system around HCSW compliance and investigating methods to constantly ensure accuracy through working with Information Services. Working with NHS Education for Scotland to continue to develop meaningful delivery of the Codes of Conduct Champions Ensure that all information around developments in Health Care Support Worker Standards is relayed timeously to senior HR managers. Working closely with colleagues across NHS Tayside directorates to embed the values and principles of the Code of Conduct. NATIONAL DRIVERS INFLUENCING NHS TAYSIDE EMPLOYABILITY SERVICES Health and Social Care Integration Welfare Reform 2020 Vision Developing Scotland s Young Workforce Creating a Fairer Scotland: Employability Support: A Discussion Paper CEL23(2010) - Healthcare Support Workers Mandatory Induction Standards and Code of Conduct for Healthcare Support Workers and Mandatory Code of Practice for Employers of Health Care Support Workers If you have any comments or suggestions regarding this Annual Report , please be in touch with: Alison Smith: -alison.smith10@nhs.net HR Lead, Employability Services Kings Cross, Dundee DD3 8EA 3

184 PUBLIC ENGAGEMENT ACTIVITY SUMMARY TAYSIDE EMPLOYABILITY SERVICES GUIDING PRINCIPLES All Employability Services programmes reflect NHS Tayside aims visions and values together with NHS Tayside Equality and Diversity policies in line with corporate social responsibility and organisational governance Employability Services processes are reviewed annually in line with NHS Tayside Governance. ACTIVITY EMPLOYABILITY PROGRAMMES Working with multi agency partners to develop skills based programmes providing relevant certification and qualification in line with national, local and organisational drivers. Ensuring programmes reflect the aims visions and values of health and social care within each locality Ensuring ongoing programme review in line with locality profiles; reflecting national drivers, including the Scottish Credit and Qualifications Framework. Working with health and social care colleagues to review Employability delivery against a background of Welfare Reform YOUNG PEOPLE Liaison maintained with partners across education, and the Third Sector delivering work experience for young people experiencing barriers to positive destinations Working with Dundee City Council and multi agency partners to further develop the Dundee Employability pipeline Working with NHSTayside Employability and Welfare Reform Group to inform the welfare reform agenda. Working with Department of Work and Pensions though work experience opportunities to break down barriers to employment across Tayside HEALTH CARE SUPPORT WORKERS Work continued with NHS Tayside partners and NHS Education for Scotland (NES) to support Health Care Support Staff to full awareness of the aims vision and values of the organisation through induction processes and application of the Code of Conduct Maintaining compliance records, and reviewing the process to ensure accuracy of reporting. Supporting staff experiencing difficulties around completion of the Induction Workbook through ensuring support mechanisms are accessed Working with NHS Colleagues and NES to deliver programmes to promote the Code of Conduct to clinical support workers Working with NHS Colleagues and NES to develop a system to deliver Code of Conduct training to Support Workers who do not have a directly clinical remit. Working with Learning and Development, Business and Administration colleagues across NHS Tayside and NHS Education for Scotland to further develop Business and Administration pathways and educational framework, Providing work experience and support in placements for Looked After Children Providing work experience for Young people referred through the Third Sector and supported by the Employability Fund 4

185 Clearly identified uniforms re provided for all groups as required. Funding sources vary in line with the referring agency NHS TAYSIDE EMPLOYABILITY SERVICES ACTIVITY This Annual Report summarises NHS Tayside Employability Services activities for and outlines proposals for The core purpose of Employability Services remains to work with multi agency partners to promote opportunities leading to positive destinations for people experiencing barriers to work within Tayside. All Employability Services activity is based on strong governance reflecting organisational aims, vision and values. Key national drivers relate to: Engagement with local populations through multi agency partnerships to mitigate the effects of joblessness and promote positive destinations including employment. Developing programmes to promote employment and career skills applicable across the care sector to mitigate the impact of Welfare Reform and enhance delivery to patients and service users. Providing information and experience for young people to promote progression to positive destinations as outlined in Developing Scotland s Young Workforce EMPLOYABILITY SERVICES STANDARD PROCESSES The following processes apply to all students accessing employability programmes across NHS Tayside OHSAS Each student must comply with mandatory health screening delivered by the Occupational Health and Safety Advisory Service (OHSAS) Uniform Policy All students are fully informed of the uniform policy with regard to home laundering. Disclosure Scotland All students undertaking programmes working directly with patients and service users must join the Protection of Vulnerable Groups (PVG) scheme Issues highlighted on individual PVG declarations are dealt with using established HR processes, with the student receiving any required support from participating partners. In some instances, continuation on the course may cease, or the offer of a guaranteed interview may be withdrawn. Communication Employability services ensure that updates to all relevant NHS Tayside committees and departments are provided as required through attendance and or dissemination of reports and that governance processes are maintained In , stronger partnerships involving Nursing and Allied Health Professional Education developed around the delivery of Health Care Support Worker Induction Standards and Codes of Conduct focusing in on clinical staff. Strong relationships were also maintained with STEM staff and representatives of catering and domestic staff and will be crucial in as the Code of Conduct for Non Clinical staff is rolled out. Employability and Employment Transition The Guaranteed Interview scheme which provides access to jobs within NHS Tayside for a period of up to 6 months following course completion is accessible only to participants in identified programmes who have successfully completed, receiving either certification, qualification or a robust reference depending on the type of programme undertaken. 5

186 The guaranteed interview process is made available by participating partners including all local Councils, Gowrie Care and the University of Dundee. Those applying to NHS Tayside must adhere to NHS Tayside policies and procedures, and those eligible will have access to clearly marked online application forms and all processes have been agreed with Human Resources Recruitment. Skills Development Scotland and Jobcentre Plus continue to provide support for participating students finding difficulty in obtaining employment. EMPLOYABILITY PROGRAMMES In Employability Services continued to work with partners across health, social care and the independent sector to develop programmes to contribute positively to the employability agenda Dundee Cohort 30 PRE EMPLOYMENT PROGRAMMES Eligibility for pre employment programmes remains via Jobcentre Plus and is subject to the receipt of benefit; access to which is retained throughout each course, but there is not gender or age bias in any of the programmes. Funding through Skills Development Scotland is reviewed annually. Successful funding bids are consequent to the number of job outcomes and positive destinations in the previous fiscal year. Bids are prepared by College business units with information provided by NHS Tayside and partners. Perth Cohort 16 The courses vary in length between 6 and 7 weeks and are supported by all local councils and colleges. (Appendix 1) Dundee City Council also provides support for people experiencing literacy and numeracy problems at all levels. Delivery of training, including mandatory skills is via local Colleges, with essential input from NHS Tayside and Council partners. Work placement opportunities are provided by NHS Tayside, (Appendix 2) local councils and the independent sector Angus Cohort 20 6

187 Figures to Date students who had successfully completed a pre employment course after October 2014 and before March 2015 were tracked in line with funding agency requirements over a period of 6 months. As the tracking period extended beyond March , these student outcomes are included in this report. Tracking Totals Job NHS FE/HE 2015 outcomes Jobs Angus Dundee P+K % 64% 20 3 Fiscal Year including tracking While issues related to achieving employment remain associated with job availability, the level of achievement is influenced by additional barriers including child care responsibilities and, increasingly, elder care. Lack of transportation in rural areas, can also cause additional barriers for students without a history of study and with issues relating to lack of employment over a prolonged period Other difficulties relate to the time taken to process job applications across the care sector, due to the necessity for PVG approval, health checks and references. A key feature of this suite of programmes is that through experiencing the reality of the working environment allows students to decide if a career in care is a realistic option for them and if they have a real desire to build a career in this sector. Courtney s story After 31 March 2015 and before 31 March students accessed the pre employment courses across Tayside. Of this number, 27 remain with the tracking period, outcomes are as follows Totals Job Outcomes NHS Jobs Dundee P+K % 58% FE/HE Overall, and excluding those within the required tracking period, Total outcomes from 30 November March 2016 are as follows Totals Job NHS FE/HE 2016 outcomes Jobs Angus Dundee P+K % 62% 26 2 Of the totals, 19 (46%) students within the group of 42 still in tracking have achieved a positive outcome to date. When I was at school, I wanted to be a Sports Coach and was accepted on the course at Dundee College. I was 16. Two weeks after starting, I found out that I was pregnant. I was really happy with this but scared and a little shocked and I knew that this would change my life and all my plans, but I kept on at College I was still at College on my due date! I had my lovely little girl in the summer holidays and I went back to College when she was 12 weeks old. It was hard, but I got a routine going and had so much help from my Mum and the family. I had my 7

188 own place as I felt it was important for my daughter and me to start as we meant to go on. I stayed at College for two more years and finished the course, and I had the option of going to University but I needed to find a job to support my daughter and me. But I wanted a job that would be meaningful and those jobs were not easy to find. I heard about the Healthcare Academy, and asked the Jobcentre to put me forward. I applied and was interviewed and accepted. I really enjoyed the course and the placements gave me a good idea of where I d like to be, but I always had my mind on a job at the end. I applied for every job I could and was lucky one of my first applications was successful and I am now a Physiotherapy Assistant. It s perfect for me as I can use my Sports Coach training and I ve got the mandatory skills through the Healthcare Academy I enjoy this job, and I enjoy coming to work. The satisfaction of working in a team helping a patient back to independence is huge. I can t say where I ll be in the next ten years, but I would like it to be working in Physiotherapy, in the National Health Service Anna s Story I am a scientist, and when I was made redundant after 10 years in my job I was worried because I had been out of education for so long. At that time, I also became a carer for a relative and learned at first hand of the importance of the different areas of care. I was nurse, dietitian, therapist and I thought, maybe I could learn to work in this area. So I applied to the Health and Social Care Academy in Perth. I had thought that I might come into nursing, starting as a Health Care Assistant and getting to know the work that way. The course was ideal for me as it gave me practice in clinical areas, but more than anything, it gave me back my confidence. I made friends with the others on my cohort and realised that being unemployed can happen to anyone. The confidence I gained helped me so much with interviews and dealing with other people and while I was still on the course, I was really happy to be offered a job in Tayside Pharmaceuticals But I wanted to finish the course, as it gave me a huge insight into the whole system of the NHS, but I have to say that more than anything gave me back my confidence. I did not move into Nursing, and I am back in a lab extending and developing my skills all the time. The training here is fantastic, and those of us working in Tayside Pharmaceuticals look after each other. I am part of a team that has a massive range of activity and supports so many essential areas in the organisation. I love it. QUALIFICATION BASED PROGRAMMES Delivery of qualification based programmes continued through Dundee & Angus College and Partners SVQ2 Business and Administration; Delivered in partnership with Dundee & Angus College and Dundee University This 32 week course provides students with a national certificate in Business and Administration, in addition to a full SVQ2 award in Business and administration 8

189 The Course is unique in that by making work experience available during the academic year, (Appendix 3) it provides Business and Administration students with a qualification normally only achieved after gaining employment, and with therefore provide extra support for people looking for a positive destination All 20 students completed the Course, with all 20 achieving the National certificate in Business and Administration, and 15 of the group also achieving the full SVQ 2 in Business and Administration. Students were only eligible to apply for positions in NHS Tayside if successful in achieving the full SVQ2. Of this group of 15, 12 obtained employment; 1 student has returned to Further Education and the remaining 2 have opted to defer employment for personal reasons Jennifer s Story Totals Full Job FE/HE SVQ2 Outcomes % 80% 7% and my right hand and leg were affected. I had to leave University, but after 3 months at the Centre for Brain Injury with the help of all the staff, and especially the Speech and Language Therapists, I got my life back (sort of) and got a job in retail. But the job was taking me nowhere, and in 2014, I lost my Mum. I felt then, it was time to change direction, so I applied to Dundee & Angus College to study the SVQ2 in Business and Administration through the Administration Academy. I studied at College for 2 days and spent 2 days on placement in the University of Dundee Medical School, and in October 2015, was successful in obtaining a temporary post with Tayside Pharmaceuticals. I love working in Administration, it s something I have always wanted to do, and I feel so lucky because I am working with a lovely group of people, and I feel that working for the NHS means that I am working in a small community, for the wider community. I went to College because this is something I love doing; but also, for my Mum, and I think she would be proud of me for everything that I have achieved. I m so thankful for all the help I have had and just want to go on to a long and fulfilling career. SVQ2 Social Work and Health and Delivered in Partnership with Dundee & Angus College, Dundee City Social Work Department and Gowrie Care This programme provides a qualification recognised across the care sector and is the base line qualification required by Social Care Officers working with Local Authorities and in the Independent Care Sector 27 placements were offered with each partner, Dundee City Council, Gowrie Care and NHS Tayside offering nine places each. When I left school, I went to Abertay University to study BA (Hons) Business and Administration, but nine years ago, when I was eighteen, my life was changed when I suffered a stroke. I lost my voice, The interview process for this group has become more focused with a rigorous interview procedure including a written test reflecting on the values and principles required in care. As in previous years, placements were provided by all partners. In NHS Tayside, focus was on Care of the Elderly including Psychiatry of Old Age and 9

190 Mental Health but specialist units accessed by this course continued to support these students. Each student accessed the same placement for 25 week for either two or three days each week. The same days are identified for continuity. Students from this course are not given access to the Guaranteed Interview until Employability Services receives confirmation that they have successfully completed both the SVQ2 and the Course with good attendance and references Total outcomes for cannot be reported at this time as all those students who successfully complete the course have a grace time of 6 months in which to access the Guaranteed Interview process. This is in line with all other employability services programmes; however, outcomes for the previous year are recorded below Of 26 students completing the course, 24 (93%) achieved the full SVQ2. Of those achieving the SVQ2, there were 20 (83%) confirmed employment outcomes after the grace period of 6 months. Within this group, one student was considering return to education and 2 students without employment were also considering this option. Completed Achieved Confirmed NHS SVQ Employment Employment Karen s story I was at a stage in my life when my family were older and did not need me so much at home, and I wanted a career that was fulfilling. I had applied to the NHS with no joy, but I wanted to work in care, so I applied to the Health and Social Care Academy with the aim of gaining an SVQ2 in Health and Social Care. I really enjoyed the course, and as a group we became very close and supportive of each other, but I also had an excellent placement in Nuclear Medicine with an incredible mentor in Elaine Duncan who was amazing and made me see the big picture that is the NHS. I had not thought of science and its impact on care before This course gave me the opportunity to try something new and gain a qualification too and it is not until someone like Elaine opens the door to show you how big the organisation is that you see what you can do personally. I learned through the College, and especially through the placement that if your confidence grows then you are not frightened of the possibilities any more. I know that my skill set is much bigger now. After gaining the SVQ2, I worked in Radiology on a 6 month temporary contract and that led to my present job as an Ultrasound Screener in Radiology. I have been encouraged so much by my department I can t even say my new department because I feel like I have been here forever and they supported me to another qualification I have successfully completed my Triple AAA Screening Course at Glasgow Caledonian University. I am so busy and happy each day is different and I know that I am helping people Ten Years from now I would like to have my degree in Radiology, but whatever happens, I know that I will never stop learning. Course content and locations are described in Appendix 4. YOUNG PEOPLE Close partnership working between NHS Tayside, Local Councils and Third and Independent sector training providers has enabled work experience opportunities for young people between the ages 10

191 of (Appendix 5) This programme has been important in terms of engagement with individual progression through employability pipelines and to build the confidence of those young people participating. Involvement of referring third sector partners as mentors during the placement of up to 13 weeks has both provided the continuity that vulnerable young people may need and also allowed NHS Tayside staff to work closely with professionals from another sector, widening awareness of roles and the potential of skills exchange within both groups. Routine meetings with referring agencies and updates around activity and outcome are part of this process. Additionally each partner organisation adheres to an agreement around activity, and an evaluation process has been developed for young people to provide valuable feedback concerning the placement experience The numbers involved in this programme have decreased with fewer referrals from Third Sector agencies. Potential reasons for this include funding issues and greater focus on apprenticeships across all sectors. This does have an effect of reducing opportunities for young people over the age of nineteen years or who have no recognisable scholastic achievement and who are therefore unable to apply for the majority of available Modern Apprenticeships The Employability Fund programme is, however delivered by NHS Tayside through Employability Services in line with the organisation s commitment to supporting young people across the region and providing opportunities to positive destinations. Outcomes for this programme are now related only to completion of the work experience opportunity and provision of a reference for the young person to progress to a positive stage in their journey. Partner Agencies working with NHS Tayside in were: - Barnardos Craigowl Communities Dundee and Angus College ENABLE Rathbone Dundee City Council Angus Council Employment comparison for the age group between May 2015 and March 2016 is as follows, with a slight rise in unemployment in Angus for this group, but an increase in employment on Dundee City and Perth + Kinross % Local Population Number May 2015 Angus Dundee City Perth & Kinross May2016 Angus Dundee Perth and Kinross % Scottish Population In there was greater liaison with local councils for placement provision. There were fewer numbers, but placements were carefully chosen for a more vulnerable group when working with council initiatives such as Stepping Stones in Angus, and under the aegis of NHS Tayside s corporate parenting policy For those young people unable to access placement or who were not ready for work experience, partners across non clinical areas agreed to information tours within their departments to gain an idea of the working environment. Participating departments included Property Services, Medical Physics, and Wheelchair Services. Each of these departments had previously offered placements for young people requiring robust support. Support particularly related to:- 11

192 Lack of confidence or fear in accessing the workplace Lack of understanding of commitment to attend work placements Transitioning to independent living Mental Health or physical disability issues Practical issues around child support, finance, and transport Literacy and Numeracy Employability services continue to represent NHS Tayside on the Developing Young People group in Dundee. The Dundee Partnership, led by Dundee Chamber were successful in a bid to the Scottish Government to employ a dedicated team to support private businesses to provide employment opportunities for Young People in Dundee NHS Tayside will remain on the group to provide insight into employment and careers within the NHS. COMMUNITY LIAISON Employability Services continued to work with colleagues in Human Resources and the Third Sector to provide awareness of career opportunities within the NHS. Following a successful tour of Blood Sciences, Tayside Pharmaceuticals and Medical Physics, placements were agreed for members of Dundee International Women s centre in Blood Sciences, however, due to staff capacity, these could not go ahead. Discussion with the community groups at a later stage has resulted in the provision of information around potential employment and employability related courses delivered by partner colleges. As a result of liaison with the group and with colleagues in STEM areas, Finance, Procurement and Allied Health Professions information events will be trialled, initially in Dundee, to provide insight for people form community groups as to how to enter the NHS or how to align existing qualifications with NHS statutory requirements. Work continued over the year liaison with the Department of Work and Pensions to provide taster work experience sessions within the organisation and guidance on employment requirements within NHS Tayside. Placements were provided within Property Services and Learning and Development for people experiencing redundancy from REMPLOY EMPLOYABILITY AND WELFARE REFORM Welfare Reform Group Employability Services continued to commit to support local populations through involvement with the NHS Tayside Employability and Welfare Reform Group and liaison with employability focused partners involved in delivery of the Employability Pipeline, bility-pipeline Partnership working with this group has allowed dissemination of crucial information relating to mechanisms intended to mitigate the impact of welfare reform to students of all programmes; and to inform colleagues wishing to understand more around the barriers to employment experienced by Employability Services students in addition to the more general population. Employability Pipeline (Dundee) Following a commissioned review by Dundee City Council concerning the City based Employability Pipeline; Work Groups were established to address the issues of :- Labour Market Intelligence The demand led approach Integrating services for those furthest from work Joint staff development Co-commissioning Supporting progression in work Performance measurement, management and improvement Work is ongoing with City Council, independent and Third Sector partners and NHS Tayside to refine and review the role and design of the pipeline in line with the City wide profile This initial work will complete in summer 2016, and will then provide clarity around further required activity. HEALTH CARE SUPPORT WORKER INDUCTION STANDARDS 12

193 The Health Care Support Worker Agenda continues to operate under CEL 23(2010) There have been no meetings at the Scottish Government over the past year; however recommendations around further developing the Induction standards and Codes of Conduct programme are included in ongoing discussions at strategic level around regulation. Workbook completion compliance remained at over 90% throughout , with a review of the recording process initiated in March 2016 to ensure accuracy is maintained. Support for those experiencing difficulty with the workbooks remains available through the commitment of training officers across the organisation. Quality Assurance The quality assurance process used in Dumfries and Galloway was examined and adopted in essentials for NHS Tayside but due to the size and focus on all job families in NHS Tayside, this quality assurance process will require modification to be fully fit for NHS Tayside. This development is ongoing and includes both clinical and non clinical staff in the process. The successful bid to NHS education for SCOTLAND to promote the Health Care Support Worker Code of Conduct through development of Code Champions resulted in a positively received presentation to an invited audience at an event hosted by NES in October NHS Tayside were consequently successful with a second bid to further develop the Code, and this has been addressed through presentations to small groups with a conference/training event planned for May 2016 Discussions with Senior Charge Nurses, primarily from Psychiatry of Old Age - and Senior Allied Health Professional staff supporting the project have indicated that modifications to the time scale of the programme would also be welcomed to allow information on the Codes to be disseminated at regulated staff team meetings in addition to longer sessions aimed at support staff A timetable is also under development to provide a similar process for support staff who do not provide direct clinical intervention. NATIONAL INITIATIVES Employability Services has been working closely with NHS Education for Scotland in development of the Career Framework for Business and Administration (B+A) staff. This ongoing work has been important in giving Business and Administration staff a voice and an awareness of career opportunities. This group is often overlooked in terms of funding and recognition. This work initiated by NES recognises the crucial role played by B+A staff who enable clinical groups to provide essential services to patients and service users. NHS TAYSIDE EMPLOYABILITY SERVICES OBJECTIVES AND PROPOSED DEVELOPMENTS FOR Objectives relate to national, regional and organisational drivers. Focus for remains on robust partnership working against a background of Health and Social care integration and significant social and welfare reforms. Work with multi agency partners to develop and refine all pre employment programmes, referring to national drivers and legislation. Work with multi agency partners to ensure that programmes reflect local population profiles Work with partners in the community to showcase opportunities within NHS Tayside and signpost methods of progression Ensure placements provided are fit for purpose and that applied governance is regularly reviewed. Continue to liaise with training providers for Young People accessing the Employability Fund ensuring the process in clear and fully supportive at all levels Work with partners as directed by HR Head of Resourcing to develop a clear 13

194 support framework for Young People accessing the Employability Fund Work with internal and external partners including NHS Education for Scotland to promote the career framework for Business and Administration staff Work with internal and external partners including the Scottish government and NHS Education for Scotland to promote the Health Care support Workers Induction Standards and Codes of Conduct 14

195 APPENDIX 1 NHS TAYSIDE HEALTHCARE ACADEMY PRE EMPLOYMENT COURSE ELEMENTS PRE EMPLOYMENT PROGRAMME CONTENT CONTENT All Mandatory Training reflects Health Care Support Worker Induction Standards RATIONALE DURATION DELIVERY Care Values, Ethics and Codes of Conduct Care values underpin delivery of the programme and reflect Health Care Support Worker Induction Standards emphasising patient focus and awareness of patient, public and staff needs when in the care environment. Ongoing throughout College, NHS Tayside and partners e.g. social work and third sector delivery Communication Skills Emphasis on types of communication in the working environment and when dealing with patients, the public and staff. Emphasis on customer care approach 2 sessions embedded in programmes College Delivery reinforced on Placements De escalation This is an awareness session. No student can be regarded as trained in de escalation techniques, but will have a clear outline of processes to be followed with respect to gaining assistance as necessary. 1 session, including Q+A Dundee Learning Disability Services Employability Students are given support to develop skills relating to completion of application forms and writing of CV for jobs outside the public sector Mock interviews and feedback from Mock Interviews Interviews to access the Nurse Bank 8 sessions and reiterated throughout course College and NHS Tayside Delivery Social Care included in Angus and Perth First Aid Awareness First Aid is presented as an awareness session. In line with NHS Tayside Policy, First Aid is administered within the organisation only by a designated First Aider who has achieved a valid First Aid certificate. 1 session College Delivery Food Hygiene In line with mandatory requirements Online examination leading to REHIS certification 1 day ( 2 sessions) College Delivery All Colleges receive REHIS certification Health and Safety Presented in line with mandatory health and safety awareness. Online examination 1 day (2 sessions) College Delivery

196 CONTENT All Mandatory Training reflects Health Care Support Worker Induction Standards Infection Control RATIONALE DURATION DELIVERY Required as a mandatory skill and emphasised throughout the course and on placement. Based on NHS Tayside Infection control policy Online examination leading to REHIS certification. 1 day (2 sessions) College and NHST Delivery. Dundee & Angus, candidates receive REHIS certification Information Technology (Basic) Introduction to IT, including Power Point 1 day (2 sessions) College Delivery Literacy /Numeracy Identification of literacy or numeracy issues through routine College activity and any necessary support put in place. Dundee City Council providing additional support through Discover Learning Ongoing 2 sessions College Delivery Dundee City Council Manual Handling Required as a Mandatory Skill; essential and must be delivered prior to any student accessing placement. 2 days (4 sessions) Occupational Health, Safety and Advisory Service (OHSAS). Pre placement education day This is delivered by the Clinical Educator from Nursing Education, Ninewells. The purpose of the session is to provide students with an awareness of the scope of the likely duties they may be asked to complete on placement This is a hands on session that generates confidence inpatient handling in preparation for placement Dundee & Angus To commence in Perth Clinical Educator, Nursing Education, Nursing Directorate Ninewells Hospital 1 day 2 sessions Placements Preparation Experience Reflection This aspect of the programme is crucial to allow the students to develop an understanding of the reality of working within the care sector. Students will undergo at least 2 placements in either health or social care, and across both clinical areas and non clinical support service areas and in the independent sector in both Angus and Perth & Kinross. Student preference is considered but students are encouraged to try new experiences and areas. Dundee & Angus 15 days (30 sessions) Perth 10 days (20 sessions) Placements are provided within NHS Tayside and partner social care placements. Perth and Kinross is working towards incorporating the independent sector in line with local profiles Presentations Integral to communication skills, IT development and confidence building. Students are encouraged to focus on a health or social care related issue for this session. Presentations are given to the peer group 2 sessions. College

197 and to invited guests. CONTENT All Mandatory Training reflects Health Care Support Worker Induction Standards RATIONALE DURATION DELIVERY Skills and Awareness: Clinical Skills Dementia Visit to Clinical Skills area within Ninewells hospital to gain an awareness of skills required in clinical areas Supporting Dementia awareness in line with organisational and national policy 1 session 1 session NHS Tayside Clinical Skills Centre College with guest speakers from health and social care provide input to all sessions Drug and Alcohol Awareness Awareness of the personal and societal effects of drugs and alcohol in their relation to mental health issues. 1 session Equality and Diversity Awareness Highlighting issues related to Equality and diversity within organisational core values. Linking into Dignity at Work. NB Academy programmes are regularly measured against the NHS Tayside Equality and Diversity Impact Assessment Toolkit. 1 session Learning Disabilities Understanding and discussing the barriers faced by people with Learning Disabilities and the direction of support within health, social care and across the community. 1 session Mental Health issues Including Understanding and discussing the barriers faced by people with Mental Health Issues and the direction of support within health, social care and across the community. 1 session Social Care Specific Issues Understanding the development of the integration agenda, individual enablement and the role of the wider multi disciplinary team, including carers Ongoing through course Healthy Working Lives Understanding the importance of promoting positive health and well being through delivery of health improvement activities particularly in areas of deprivation using a multi disciplinary approach 1 session NHS Tayside Healthy Working Lives Community Health Specialist Nurse.

198 CONTENT All Mandatory Training reflects Health Care Support Worker Induction Standards RATIONALE DURATION DELIVERY Wheelchair Awareness An awareness of the range of wheelchairs used within NHS Tayside including attendant controlled, self propelled and battery operated, together with an awareness of the variety of cushioning used and how this may impact on care within a ward or home situation. 1 session at Ninewells NHS Tayside Wheelchair and Seating Services Ambulance Service Awareness A visit to the Ambulance service to give an awareness of the importance of emergency services and close communication between departments. 1 session at Scottish Ambulance Service Dundee Scottish Ambulance Service manager NB Course evaluation Celebration of achievement Guaranteed Interview Course evaluation is required to ensure course components reflect national and organisational drivers in terms of delivery, but is also crucial to note any issues that have been raised relating to students access to the course A celebration of achievement is always scheduled for the last session of the course. Key elements of the students journey are presented to an invited audience, including family and friends, and students receive certificates from an invited Guest. From the date of completion, each student who has successfully completed the course will receive guaranteed interviews for essential support service jobs across the organisation, with the caveat that they meet the person specification. 1 session Delivered at College with input from partners constantly under review 1 session Delivered by host College with presentations from partners. Employability Services team in close collaboration with NHS Recruitment team and managers

199 PRE EMPLOYMENT PROGRAMMES PLACEMENT LOCATION APPENDIX 2 PLACEMENT ANGUS placements also provided by Angus Council and Gowrie Care Medicine: Wards Arbroath Infirmary Out Patients Department: Arbroath Infirmary Stracathro Hospital, Brechin Community: GP Unit, Montrose Infirmary In patient unit Brechin infirmary Mental Health/Palliative Care: Ward 1, Inchcape Unit, Arbroath Infirmary, Susan Carnegie Centre Stracathro Hospital, Brechin Clova Ward, Whitehills Hospital, Forfar Prosen Unit, Whitehills Hospital, Forfar Independent sector Gowrie Care Social Care:- Seaton Grove, Arbroath, The Gables, Forfar, Administration Bruce House, Enablement Team, Arbroath, Early Supported Discharge Team Arbroath/Carnoustie/Montrose Ninewells Clinical DUNDEE Medicine:- Clinical Investigation, Endoscopy, Ward 1, 2 Surgery: - Wards 9, 10, Theatres, ward 25, Ophthalmology Orthopaedics Ninewells- wards 17, 18, and 19. Care of the Elderly: Wards 5&6 Ninewells Hospital Wards 4,3Ninewells- Wards 5, 6. Speech and Language Therapy Royal Victoria wards 4, 5, and 8. CBIR Learning Disability Strathmartine - Craigmill Skills Centre, Carseview Mental Health : wards 1,2,3,4 -Kingsway Care Centre, Ward 1 Carseview Dundee Healthy Living Initiative Ardler, Lochee Medical Physics Learning and Development administration Support Services :- Portering, Catering Property Services : - Estates Ninewells, Administration Property PERTH AND KINROSS Placements also provided by Perth and Kinross Council and Perth College - UHI PRI Out Patients Department Clinical and Administration Surgery wards 1 and 8 Portering Blood Sciences Human Resources Murray Royal Occupational Therapy, Garry Ward - Tummel ward Blairgowrie Community Hospital Crieff Community Hospital Occupational Therapy Social Care:-, /Lewis Place/New Rannoch Day Centre/Gleneagles Day Care/Beechgrove House/Kinnoul Day Opportunities/Housing and Community care Avenue Care Perth College :- administration, hair and beauty department

200 APPENDIX 3 QUALIFICATION BASED COURSES ADMINISTRATION ACADEMY PARTNERSHIP PLACEMENTS Ward 5 Ninewells Ward Assistant Medicine Directorate Hawkhill Medical Centre Nethergate Medical Practice Princes Street Surgery Learning and Development Procurement Property Services Medical Physics Allied Health Professions Kings Cross Nursing and Midwifery -Ninewells Physiotherapy:- Ninewells Clinical Radiology Ninewells Blood Sciences Ninewells OT Learning Disability Service & Tayberry Social Enterprise Clinical Governance and Risk ehealth Customer Services, Maryfield

201 APPENDIX 4 HEALTH AND SOCIAL CARE ACADEMY COURSE CONTENT AND PLACEMENT LOCATIONS CONTENT RATIONALE DURATION DELIVERY Care Values, Ethics and Codes of Conduct Care values underpin delivery of the programme. They reflect the Health Care Support Worker Induction Standards and emphasise patient focus and awareness of patient, public and staff needs when in the care environment. 1 session p.w.for 16 weeks and throughout course College, NHS Tayside, local Authority and third sector partners Communication Skills Embedded in Care Values and working towards SCQF level6 College Delivery reinforced on Placements Employability Dealing with qualities, skills, goal setting, CV writing, public sector applications and on line applications, IT 1 session per week for 16 weeks and throughout the course College Delivery Supplemented by partners First Aid Awareness First Aid is presented as an awareness session. In line with partners policies, First Aid is administered within the organisation only by a designated First Aider who has achieved a valid First Aid certificate. 1 day (2 sessions) College Delivery Food Hygiene In line with mandatory requirements Online examination leading to REHIS certification 1 day ( 2 sessions) College Delivery REHIS certification Health and Safety Presented in line with mandatory health and safety awareness. Online examination leading to REHIS certification 3 sessions College Delivery. REHIS certification Infection Control Embedded into practical core skills 1 session per week for 16 weeks and throughout the course College Delivery. REHIS certification Information Technology (Basic) Embedded in Communication Unit College Delivery Literacy Embedded in Communication and SVQ Ongoing College Delivery Manual Handling Required as a Mandatory Skill; essential and must be delivered prior to any student accessing placement. 3 sessions College Delivery Practical Core Skills Human Development; Hand Hygiene; Clinical waste; Disinfection. All aspects of personal care including Pressure Care, Continence Care, Diet and Nutrition, Control and Restraint. 16 weeks College Delivery

202

203 CONTENT RATIONALE DURATION DELIVERY Placements Preparation Experience Reflection This aspect of the programme is crucial to allow the students to develop an understanding of the reality of working within the care sector and to gain the work experience necessary to gain the SVQ Placements in NHS include: Orthopaedics, Care of the Elderly Mental Health, Learning Disability Renal services, Theatres Allied Health 2 days per week. October to December 3 days per week January to march 2 days per week April to June Placements provided by partners Skills and Awareness: Clinical Skills Dementia Drug and Alcohol awareness Visit to Clinical Skills area within Ninewells hospital to gain an awareness of skills required in clinical areas Supporting Dementia awareness in line with NHS Tayside and Dundee City Council and national policies This element is an awareness of the personal and societal effects of drugs and alcohol in their relation to mental health issues. Highlighting issues related to 1 session 1 session 1 session NHS Tayside Clinical Skills Centre All following sessions delivered by College +guest speakers from health & social care Equality and Diversity Awareness Equality and diversity within organisational core values. Linking into Dignity at Work. NB Academy programmes are regularly measured against the NHS Tayside Equality and Diversity Impact Assessment Toolkit. 1 session Learning Disabilities Understanding and discussing the barriers faced by people with Learning Disabilities and the direction of support within health, social care and across the community. 1 session Mental Health issues Including Understanding and discussing the barriers faced by people with Mental Health Issues and the direction of support within health, social care and across the community. 1 session Palliative Care Discussing the philosophy of Palliative Care, components of services provides and the role of carers and the multi disciplinary team across health and social care 1 session Social Care Specific Issues Understanding the development of the integration agenda, individual enablement and the role of the wider multi disciplinary team, including carers Ongoing throughout the course

204 CONTENT RATIONALE DURATION DELIVERY SVQ Health and Social Care Examples of Units: Communicate with and complete records for individuals Support the health and safety of yourself and individuals Develop your knowledge and practice Ensure your own actions support the care, protection and well being of others. To achieve the SVQ level 2, candidates are required to complete SIX Units, two Core Units, two Optional Units -the two remaining Units to be taken from either the Core or the Optional sections Celebration of Achievement College celebration with all SVQ courses 1 session Guaranteed Interview From date of completion, each student who has successfully completed the course will receive guaranteed interviews for essential support service jobs across the organisation, with the caveat that they meet the person specification. HEALTH AND SOCIAL CARE ACADEMY PARTNERSHIP HEALTHCARE PLACEMENTS LOCATION Renal Services Mental Health: Psychiatry of Old Age Kingsway Care Centre Nuclear Medicine Theatres Learning Disability: Strathmartine Orthopaedics Ninewells Ward18, Mental Health: Adult Carseview Care of the Elderly Royal Victoria:- Wards 3, 4, 5 and 8 Care of the Elderly Ninewells Wards 5 and 6 Ryehill Health Centre

205 APPENDIX 5 YOUNG PEOPLE EMPLOYABILITY FUND/LOOKED AFTER CHILDREN PLACEMENT LOCATIONS ANGUS DUNDEE PERTH AND KINROSS Admin Angus CHP Arbroath Infirmary Child Family and Public Health, Forfar Links Health Centre Montrose Property Services: -Estates Medical Physics Nursing and Midwifery Ninewells Property Services: -Administration Property Services: - Estates Portering : - Ninewells Prosthetics Support Services :- Catering Wheelchair Services Birch Avenue Day Hospital, Scone Cornhill Macmillan Centre, PRI Orthotics Podiatry Psychiatry of Old Age Nursing Administration Admin Perth CHP Admin Medical Physics

206 REFERENCES..(2016) Fair Work Convention, developing a clear blueprint for Fair Work Practices [online] Edinburgh: The Scottish.Government. Available from (2015) Creating a Fairer Scotland EMPLOYABILITY SUPPORT: A DISCUSSION PAPER[online]. Edinburgh: The Scottish ---Government. Available from (2014) Commission for Developing Scotland s Young Workforce workforce --- (2014) Public Bodies (Joint Working) (Scotland) Act (2013) Everyone matters: 2020 Workforce Vision [online]. Edinburgh: The Scottish Government. Available from (2007) Better Health, Better Care: Action Plan. Edinburgh: The Scottish Government ---. (2009) A Guide to Health Care Support Worker Education and Development [online].edinburgh The Scottish Government. Available from (2010) Chief Executive Letter (CEL) 23 Healthcare Support Workers- Mandatory Standards and Code of Conduct for Healthcare Support Workers and Mandatory Code of Practice for Employers of Healthcare Support Workers [online]. Edinburgh: The Scottish Government. Available from (2010a) The Healthcare Quality Strategy for NHS Scotland [online]. Edinburgh: The Scottish Government. Available from <

207 UPDATE EMPLOYABILITY SERVICES WORKPLAN Item 10.2 Appendix Objectives Activity Focus for :- Robust partnership working against a background of Health and Social care integration and significant social and welfare reforms. Working with multi agency partners to develop the local young workforce Developing accessible information for local community regarding access to relevant care related employability programmes Maintaining delivery of the HCSW Induction Standards and Codes of conduct across the organisation National/Organisational drivers Work with multi agency partners to develop and refine all pre employment programmes, referring to national drivers and legislation. Partnership working with the Department of Work and Pensions, SDS, local councils and Local Colleges in delivery of Pre employment training programmes x3 Dundee x2 Angus x2 Perth and Kinross o Increase engagement with private/voluntary sector Qualification based programmes o Health and Social Care Academy x 32 weeks o Administration Academy x 32 weeks o Develop system to link with Business Academy ( Dundee + Angus College) over 2 years Investigate potential for delivery of pre employment programme with Princes Trust aimed at years (2010)Equality Act (2014) Public Bodies (Joint Working) (Scotland) Act 2014 (2015) Creating a Fairer Scotland EMPLOYABILITY SUPPORT: A DISCUSSION PAPER (2016) Fair Work Convention, developing a clear blueprint for Fair Work Practices [online] Edinburgh: The Scottish.Government (2010a) The Healthcare Quality Strategy for NHS Scotland

208 Work with multi agency partners to ensure that programmes reflect local population profiles Work with partners in the community to showcase opportunities within NHS Tayside and signpost methods of progression Continue to liaise with training providers for Young People accessing the Employability Fund ensuring the process in clear and fully supportive at all levels Ensure robust partnership working with Dundee City Council, Dundee and Angus College, Rocket Science and Voluntary partnership to implement Employability Services review across City of Dundee Work with Welfare Reform group regarding analysis of population profiles including deprivation. Liaise with Perth and Kinross Employability Network to review access to NHS work placement undertake discussions with the Department of Work and Pensions and the Employment Development Unit (Dundee) to develop placement opportunities for people with significant barriers to work Work with community groups including Dundee International Women s Centre/Deaf Links and Perth and Kinross Hearing Loss. Provide opportunity to access specific areas within NHS Tayside e.g. Blood Sciences to provide information and direction for access to NHS. Work to establish placement opportunities/information service for people with hearing impairment Work with Local Councils/Department of Work and Pensions to provide opportunities on individual basis for people with disability experiencing severe barriers to work Work with Barnardos, Rathbone and HELM on a regular basis to provide placement opportunity. Ensure all governance is completed prior to placement and that guaranteed interview scheme is implemented on successful completion of work experience and in line with Certificate of Work Readiness. Identify areas for work experience placements in non clinical areas. Investigate potential for clinical placement areas. Work closely with Dundee City Council Youth team to provide work experience placements and to contribute to strategic planning for young people in Dundee. Work with Dundee and Angus Developing the Young Workforce representing NHS Tayside on this Board,contributing to 3 year planning, (2010)Equality Act (2015) Creating a Fairer Scotland EMPLOYABILITY SUPPORT: A DISCUSSION PAPER (2016) Work, health and disability: improving lives Green Paper- 2016) Work, health and disability: improving lives Green Paper- (2010)Equality Act (2014) Commission for Developing Scotland s Young Workforce (2010)Equality Act

209 Ensure work experience placements for all programmes are fit for purpose and that applied governance is regularly reviewed. Work with internal and external partners including NHS Education for Scotland to promote the career framework for Business and Administration staff Work with internal and external partners including the Scottish government and NHS Education for Scotland to promote the Health Care support Workers Induction Standards and Codes of Conduct Students on pre employment programmes will receive structured feedback from placement providers and will also provide evaluation of the placement to inform the provider of the level of support provided during the placement. The general memorandum of understanding provided for placements w reviewed annually Each student or participant of a course required to attend occupational health prior to placement PVG applied to all students/participants if the placement required this Represent NHS Tayside at NHS Education for Scotland national forum dealing with the design and delivery of a career framework for Business and Administration staff Work with Business and Administration staff across Tayside delivering information roadshows Linked national work with NHS Tayside/Dundee + Angus College/Dundee University Represent NHS Tayside at NHS Education for Scotland Fora, and maintain informal links across Scotland with Boards delivering on the HCSW Induction Standards and Codes of Conduct. Maintain Compliance recording Work with colleagues in support services to ensure support provided for staff experiencing difficulty with workbook completion Provide support sessions to individual departments to enable progression with the Induction workbooks, including relating them to the Codes of Conduct and appraisal system Continue to deliver Codes of Conduct training and approach individual departments re new Champions Work with Nursing and AHP Education leads and Education lead from NHS Education for Scotland 2013) Everyone matters: 2020 Workforce Vision 2009) A Guide to Health Care Support Worker Education and Development 2010) Chief Executive Letter (CEL) 23 Healthcare Support Workers- Mandatory Standards and Code of Conduct for Healthcare Support Workers and Mandatory Code of Practice for Employers of Healthcare Support Workers (2013) Everyone matters: 2020 Workforce Vision

210 Please note any items relating to Staff Governance business are embargoed and should not be made public until after the meeting Item 11.1 SGC/ Staff Governance Committee 14 March 2017 APF SUMMARY REPORT 23 RD NOVEMBER 2016 Minute of the Area Partnership Forum held at 1.30 pm on Wednesday 23 rd November 2016 Key Points from the meeting to highlight to Staff Governance Committee Mrs Rogers and Ms Jones gave a presentation of the Staff Appreciation and Recognition Awards Mr Smith and Mr Marshall presented our Local Partnership Fora Program Mr Courtney presented the 6 monthly update to the Staff Governance Action Plan The Fora considered a paper from Mr Bedford updating the forum on NHS Tayside s financial position Decisions for Highlighting The APF celebrated the level of positive feedback in the in-patient Patient Experience Survey Mrs Golden requested the Mental Health Continuity Plan be shared with the APF Partnership Working in practice continues to develop following The Review 1

211 Please note any items relating to Staff Governance business are embargoed and should not be made public until after the meeting DRAFT Remove draft once the policy is adopted by the Standing Committee Human Resources Research Passport Policy Policy Manager Tayside Medical Science Centre (TASC) Head of Non-Commercial Research Services Policy Established June 2010 Policy Review Period/Expiry December 2018 Policy Group Research Passport Last Updated December 2016 This policy does apply to Medical/Dental Staff UNCONTROLLED WHEN PRINTED

212 Research Passport Version Control Version Number Purpose/Change Author Date 1.0 Version Control was introduced in July 2011 and previous versions of this Policy, prior to this date, are available in the Electronic Document Store. Tayside Medical Science Centre (TASC) R&D Manager 1.1 Updated with Bribery Act 2010 J Golden March Simplified policy and clarified local requirements, amendments and renewal. L Coote J Golden December 2016 Document Control Document: Research Passport Policy Version: 2.0 Version Date: December 2016 Policy Manager: L Coote and J Golden Page 2 Review Date: December 2018

213 Contents Page Number Bribery Act Purpose And Scope 5 2. Statement Of Policy 7 3. Definitions 8 4. Responsibilities 8 5. Organisational Arrangements Key Contacts 12 Appendices Appendix 1 Research Passport Algorithm of Research Activity and 13 Pre-Engagement Checks 14 Appendix 2 Research Passport Form Version 3 15 Appendix 3 Policy Approval Checklist 22 Appendix 4 Equality Impact Assessment 23 Document Control Document: Research Passport Policy Version: 2.0 Version Date: December 2016 Policy Manager: L Coote and J Golden Page 3 Review Date: December 2018

214 Bribery Act 2010 NHS Tayside is committed to the highest standards of ethical conduct and integrity in its business activities in the UK and overseas. NHS Tayside has introduced an Anti-Bribery Programme to outline its position on preventing and prohibiting bribery, in accordance with the Bribery Act NHS Tayside will not tolerate any form of bribery by, or of, its employees, agents or consultants or any person or body acting on its behalf. Senior management is committed to implementing effective measures to prevent, monitor and eliminate bribery and every employee and associated person is responsible for maintaining the highest standards of business conduct. Under the Bribery Act 2010, a bribe is a financial or other type of advantage that is offered of requested with the: Intention of inducing or rewarding improper performance of a function or activity; or Knowledge or belief that accepting such a reward would constitute the improper performance of such a function or activity. All employees and associated persons including temporary workers, consultants, contractors, agents and subsidiaries acting for, or on behalf of, NHS Tayside are required to comply in accordance with the Bribery Act 2010 and certain actions detailed in that can result in criminal offences being committed. Any incident determined under the Bribery Act 2010 will be regarded as gross misconduct and will be investigated in accordance with the NHS Tayside Employee Conduct Policy. Document Control Document: Research Passport Policy Version: 2.0 Version Date: December 2016 Policy Manager: L Coote and J Golden Page 4 Review Date: December 2018

215 1. PURPOSE AND SCOPE The Research Passport (RP) scheme is the recognised UK wide mechanism for staff that has no contractual arrangements with the NHS to obtain an Honorary Research Contract (HRC) or Letter of Access (LOA) when they propose to carry out research in the NHS. The RP is the application form rather than the end product itself. It replaces the previous Honorary Research contract processes which varied widely across the UK NHS organisations and lead to duplication of checks, unnecessary checks, delays in study start up and cost implications for those involved. The RP is a single set of checks on a researcher conducting research in the NHS. It is a UK wide system ratified by the NHS, Higher Education Institutes (HEIs), Universities UK and the Departments of Health. It aims to streamline procedures and timelines associated with the issuing of Honorary NHS Research contracts (HRCs) and NHS Letters of Access (LoAs) to researchers who have no contractual status with the NHS but who wish to undertake research in the NHS which directly affects patient care and/or requires access to NHS facilities and resources. The system ensures that the correct pre-engagement checks are undertaken and that they are proportionate to the research risk proposed within the NHS organisations. 1.1 WHAT IS THE RESEARCH PASSPORT (RP)? A single set of pre-engagement checks on a researcher undertaking research in the NHS and which is proportionate to the research risk. The RP is a standard form which is completed by the researcher and their substantive employer and is validated by a Lead NHS organisation. The RP is the application form for either an NHS Honorary Research Contact (HRC) or Letter of Access (LoA) The completed RP should be presented to host NHS organisations to permit review, acceptance and issue of host NHS HRC or LoA for the proposed research. The RP system avoids duplication of checks and expedites review and issue of HRCs and LoAs across the NHS. There are 2 types of Research Passport available to researchers: Project specific RP Multi-project RP each of which are valid for a maximum of 3 years or up to the end date of the current employment contract of the applicant, whichever is the earlier. Project specific RPs are only suitable for researchers who are undertaking a single research project within the NHS and who will not be undertaking other research projects within the lifetime of the RP in question. Multi-project RPs are recommended if more than one research project is likely as projects can easily be added to multi-project RPs. The current maximum duration of the RP is for 3 years after which a new RP is required. Researchers wishing to continue research in NHS organisations should ideally complete a new RP application form approximately 4 weeks prior to the expiry date of the valid RP to ensure sufficient time for the processing, any new checks required and completion of the Document Control Document: Research Passport Policy Version: 2.0 Version Date: December 2016 Policy Manager: L Coote and J Golden Page 5 Review Date: December 2018

216 new RP. It is recommended that researchers discuss the requirement for Research Passport, HRCs and LoAs with their local NHS Research & Development (R&D) office or host NHS R&D office prior to completion of the paperwork. The R&D office will review the risk based on research activities and advise you as to what, if any, pre-engagement clearance checks are required. It is important that the researchers are clear and upfront as to their role and responsibilities across the research studies as this will determine the level of risk and the checks required to validate and sign off the Research Passport. Researchers must not include activities that they will not be undertaking i.e. the just in case scenario, as this may lead to incorrect level of checks being requested and the issue of inappropriate contracts. 1.2 Research is an integral part of NHS activity. Research identifies innovative ways of preventing, diagnosing and treating illness. Research provides information on the costs, effectiveness and broader impact of health technologies. Research provides the evidence base for the organisation, management and delivery of healthcare services to increase the quality of patient care, ensure better patient outcomes and contribute to improved population health. Research can lead to significant cost savings to the NHS organisation e.g. drugs provided by the manufacturer or Sponsor. The RP ensures appropriate pre-engagement checks are undertaken and appropriate governance by the NHS with respect to researcher access and use of NHS facilities. Correct use and adoption of the RP expedites access of researchers and study initiation site. 1.3 Inconsistency and the lack of clear guidance about the requirement for Honorary Research Contracts have meant that they have been issued inappropriately in parts of the NHS. Where they have been under-used, this has resulted in lack of clarity about liability. Where they have been over-used, this has not only wasted the resources and time of the Workforce Directorates, Research and Development Departments and researchers themselves, but has also placed inappropriate liability on NHS organisations. 1.4 Duplication of pre-engagement checks and inappropriate use of Honorary Research Contracts wastes considerable amounts of time and resource for both Higher Education Institutions (HEIs) and NHS organisations. Frustration with inconsistent approaches can harm working relationships. 1.5 NHS Tayside is a partner in the UK Clinical Research Network, and NHS Tayside has agreed to implement the Research Passports Scheme as part of relevant obligations. The Chief Scientist Office (CSO) within the Health Department of the Scottish Government is supporting Research & Development Managers across NHS organisations to adopt an approach to implementation that is as uniform as possible to reduce inconsistencies and ensure a smooth process for NHS access for researchers 1.6 Substantive employers (usually Higher Education Institutions) retain responsibility for other research activities that do not affect the NHS organisation s duty of care. Document Control Document: Research Passport Policy Version: 2.0 Version Date: December 2016 Policy Manager: L Coote and J Golden Page 6 Review Date: December 2018

217 1.7 Honorary Research Contracts do not provide a mechanism for access to confidential patient information without consent. Access to confidential patient information out-with research, which can be obtained either with patient consent or statutory support, does not require an Honorary Research Contract. 1.8 Implementation of the Research Passports must comply with anti-discrimination legislation and particular care should be taken not to include discriminatory conditions or requirements in relation to age, colour, disability or illness (including HIV/AIDs), ethnic origin, gender, marital status, nationality, race religion or belief, sexual orientation or social background. 1.9 WHO NEEDS A RP? Staff who have no contractual arrangements with the NHS wishing to undertake clinical research in the NHS require a RP. Please check with your local NHS R&D office or the host NHS R&D office to confirm if a RP is required. In Tayside it is best to contact tasctayside@nhs.net in the first instance. Researchers who have direct contact with patients/service users/children/vulnerable adults and providing prevention, diagnosis or treatment of illness Direct contact with patients/service users/children/vulnerable adults but are not providing prevention, diagnosis or treatment of illness (e.g. observer) Indirect contact with patients/service users/children/vulnerable adults and providing prevention, diagnosis or treatment of illness (e.g. telephone interview) Access to Identifiable patient information derived from health records, tissues or organs with likely impact on patient care, prevention, diagnosis or treatment of illness WHO DOES NOT NEED A RP? Substantive employees of the NHS Individuals holding Honorary Clinical contracts with the NHS such as Clinical Academics Independent contractors e.g. GPs and their employees Commercial research organisations e.g. Pharmaceutical Industry employees and Contract research organisations. Research not involving the NHS, patients or NHS resources Students undertaking research and who will be supervised at all times by substantive or honorary clinical or honorary research staff. 2. STATEMENT OF POLICY This policy applies to Tayside researchers undertaking multi-centre research only. It also applies to external researchers wishing to undertake research in NHS Tayside and who are deemed to require a Research Passport as outlined above. NHS Tayside agrees to accept RP applications from external researchers which have been validated by a Lead NHS organisation and which are within the expiry date of the RP and will issue either a HRC or LoA, provided the pre-engagement checks are commensurate with the research risk for NHS Tayside. We reserve the right to request additional pre-engagement checks where these have not been completed and are deemed necessary for the research Document Control Document: Research Passport Policy Version: 2.0 Version Date: December 2016 Policy Manager: L Coote and J Golden Page 7 Review Date: December 2018

218 proposed within NHS Tayside. Tayside researchers undertaking single centre research in Tayside are not required to complete the RP unless and until they require access to other Health Boards for multicentre research. In this case, the substantive employer HR team will liaise directly with NHS HR team to ensure appropriate pre-engagement checks proportionate to research activity and in line with the RP requirements are undertaken. Tayside researchers planning on undertaking multicentre research in the NHS should contact the Tayside Medical Science Centre Research and Development team at to discuss and complete the RP. 3. DEFINITIONS 3.1 RP - Research Passport This is one standard form for each researcher that provides evidence of one set of checks on a researcher conducting research in the NHS. The form is completed by the researcher and her/his employer and validated by a lead NHS organisation. The completed Research Passport is presented to all other relevant NHS organisations in order for an Honorary Research Contract or Letter of Access to be issued rapidly with no duplication of checks. 3.2 HRC - Honorary Research Contract This contract is between the NHS organisation and the employer of the researcher. The Honorary Research Contract allows the researcher access to NHS Tayside premises, patients, clinical samples and clinical personal information. 3.3 LoA - Letter of Access This will be issued to those who do not require an Honorary Research Contract. The standard letter concerns responsibilities of such researchers and may be used for one project or a series of projects. 3.4 HEI Higher Education Institute Higher education institutions include traditional universities and profession-oriented institutions. 4. RESPONSIBILITIES 4.1 NHS Tayside is responsible for: ensuring a Research Passport policy is in place for NHS Tayside the implementation and observance of the Research Passport policy ensuring NHS Tayside directorates and the research community are made aware of the protocol and their responsibilities within it, and that staff are appropriately trained. 4.2 The Tayside Medical Science Centre (TASC) R&D team is responsible for: Providing guidance, support and sign off on Research passport applications for Tayside individuals seeking to conduct multicentre research out with NHS Tayside Document Control Document: Research Passport Policy Version: 2.0 Version Date: December 2016 Policy Manager: L Coote and J Golden Page 8 Review Date: December 2018

219 Providing guidance, support and sign off on Research passport applications for external researchers seeking to conduct clinical research within NHS Tayside as host or lead NHS board. providing a point of contact for externally employed individuals seeking to conduct research in NHS Tayside assessing the need for an Honorary Research Contract from the individual s employment status and the nature of the proposed research project or programme assessing the need for a Letter of Access from the individual s employment status and the nature of the proposed research project or programme issuing a standard Letter of Access, where an Honorary Research Contract or further pre-engagement checks are not needed ensuring that Research Passport applications are forwarded to the Workforce Directorate with the relevant supporting documents so that an Honorary Research Contract can be issued if needed assisting, reviewing and approving amendments to the Research Passport applications. training TASC staff within NHS Tayside to ensure compliance through management of Research Passport applications maintaining an up to date tracker of Research Passports, Honorary research contracts and Letters of Access issued by NHS Tayside helping researchers with renewal of RPs auditing NHS Tayside s performance in using the Research Passports process to speed up researcher access to the NHS. 4.3 The HR &OD Directorate is responsible for: working closely with TASC R&D team and researchers ensuring all appropriate risk based pre-engagement checks are undertaken for Tayside researchers planning to undertake multicentre research. ensuring that an Honorary Research Contract is issued in response to a request from TASC R&D team for an external researcher where a valid Research Passport is in place, checked and signed off by TASC R&D as either the Lead or host R&D office. work in partnership with TASC staff within NHS Tayside to ensure compliance with the Research Passport Policy work with TASC to audit compliance, in particular in the monitoring of expiry/renewal of honorary contracts and Letters of Access. Document Control Document: Research Passport Policy Version: 2.0 Version Date: December 2016 Policy Manager: L Coote and J Golden Page 9 Review Date: December 2018

220 5. ORGANISATIONAL ARRANGEMENTS Tayside researchers wishing to undertake multicentre clinical research in the NHS should contact the TASC generic mailbox at providing details of the research proposal(s), their role and details of responsibilities in the studies for TASC review of RP/HRC/LoA requirements. A member of the TASC R&D team will get back to you to provide advice and work with you on the RP application and requirements. Similarly, external researchers wishing to undertake research in NHS Tayside should contact the TASC generic mailbox at tasctayside@nhs.net providing details of the research proposal(s), their role and details of responsibilities in the studies for TASC review of RP/HRC/LoA requirements. A member of the TASC R&D team will get back to you to provide advice and work with you on the RP application and requirements. RP Process where Tayside is the Lead NHS organisation 5.1 Following discussion with and guidance from the NHS R&D department, the researcher completes sections 1-3 of the RP application form. This should then be passed to the appropriate substantial employer representative to complete the next section, section The substantial employer e.g. line manager or academic supervisor, completes section 4 of the RP form. This is then passed on to the Human resources (HR) department of the substantive employer. 5.3 The Human Resources (HR) department of the substantive employer, or the Registry at a student s place of study, completes section 5 and confirms the pre-engagement checks undertaken. 5.4 The researcher may need to complete occupational health assessments and or Disclosure/Criminal record checks and/or provide additional documents to the NHS organisation. This is determined based on the proposed research activity and associated risk. The NHS R&D department reviewing the RP form will clarify the necessary preengagement checks with the researcher and HR department. 5.5 The substantive HR department signs off section 5 of the RP form and returns it to the researcher. 5.6 The researcher completes section 6 and attaches the necessary documents. This is then submitted to the Lead NHS R&D department. 5.7 The Lead NHS R&D department completes section 8 and signs it off. 5.8 The completed RP form is now a valid authorised form and is returned to the researcher. 5.9 The researcher should present this valid RP form to all host NHS R&D offices where they require access for research purposes. The host NHS organisation should accept this validated RP form and issue a HRC or LoA based on this. Document Control Document: Research Passport Policy Version: 2.0 Version Date: December 2016 Policy Manager: L Coote and J Golden Page 10 Review Date: December 2018

221 RP Process where Tayside is a Host NHS organisation rather than the Lead NHS Organisation 5.10 The external researcher presents the validated completed RP form to Tayside NHS R&D office for review The R&D team review the RP form and the proposed research activity for Tayside and assess if additional pre-engagement checks are required. If additional checks are required the researcher is informed and requested to provide evidence of the checks as soon as available If only a Letter of Access with no further pre-engagement checks required, Tayside R&D team will issue the Letter of Access using the standard template letter On receipt of completed RP form and any additional pre-engagement check evidence, the Tayside R&D liaise with NHS Tayside HR & OD Directorate/HR team to issue a HRC as required. PRE-ENGAGEMENT CHECKS REQUIRED FOR THE RP The Tayside NHS Research and Development (R&D) office will confirm what preengagement checks are required for the researcher based on the proposed research activity, risk, portfolio and RP algorithm. Disclosure/Criminal Record Checks The level of Disclosure/criminal record checks required will be dependent upon the research proposed and its associated risk. It is unlawful to ask someone to become a member of the PVG scheme if it is not required e.g. a researcher whose research involves working only with vulnerable adults would not be required to become a PVG scheme member in respect of regulated work with children. Please note that only the Applicant can provide a copy of their Disclosure certificate to the NHS organisation for review and not the substantive employer as the Registered Party. Occupational Health check - The level of Occupational Health checks required will be dependent upon the research proposed and the level of interaction with patients, staff, NHS tissues or organs on NHS premises. Researchers should liaise with R&D office to complete the proforma providing details of the level, type and frequency of interaction to enable the Occupational Health department to determine the necessary checks required. Occupational health department recommend allowing 3 weeks for review and completion of health checks. AMENDMENTS TO THE RP Amendments can be made to the RP application within its 3 year lifespan. Examples of such amendments are the following: extension of a fixed term contract to permit extending the HRC or LoAs for researcher up to a maximum of 3 years from validation by Lead NHS organisation addition of new projects the researcher will be working on. This may impact on the preengagement checks required and necessitate additional checks e.g. checked against the Disclosure and Barring Service (DBS) Barred list for adults and/or children. All amendments should be submitted to the Lead NHS organisation for review and sign off re submission to host NHS organisations. Document Control Document: Research Passport Policy Version: 2.0 Version Date: December 2016 Policy Manager: L Coote and J Golden Page 11 Review Date: December 2018

222 RP TRACKER It is the responsibility of each researcher to ensure that their RP, HRC or LoAs are in date and to work with each NHS organisation to keep them informed of all changes impacting or likely to impact on pre-engagement checks and subsequent access to the NHS. NHS Tayside R&D will hold a Research Passport tracker which will enable it to alert researchers to pending expiry dates of the RPs, HRCs and LoAs so that new RPs can be completed as required in a timely manner. 6. KEY CONTACTS Tayside R&D office generic mailbox tasctayside@nhs.net Liz Coote, Head of Non-Commercial Research Services (TASC) liz.coote@nhs.net Patricia McLean, HR Lead - Employment Services NHS Tayside patricia.mclean@nhs.net Callum McConnell, Employment Services Assistant, HR & OD Directorate NHS Tayside callum.mcconnell@nhs.net Morag Souter Employment Services Assistant, HR & OD Directorate NHS Tayside msouter@nhs.net Gillian Boyd, HR Officer, University of Dundee g.boyd@dundee.ac.uk Suzanne Esplin, HR Officer, University of Dundee s.esplin@dundee.ac.uk Isla Racionzer HR Recruitment Assistant, University of Dundee i.a.racionzer@dundee.ac.uk RELATED INFORMATION SOURCES Document Control Document: Research Passport Policy Version: 2.0 Version Date: December 2016 Policy Manager: L Coote and J Golden Page 12 Review Date: December 2018

223 Appendix 1 Research Passport Algorithm of Research Activity and Pre-Engagement Checks (Excerpt from HR Good Practice Resource Pack - Version 3.0 September 2012) Document Control Document: Research Passport Policy Version: 2.0 Version Date: December 2016 Policy Manager: L Coote and J Golden Page 13 Review Date: December 2018

224 Document Control Document: Research Passport Policy Version: 2.0 Version Date: December 2016 Policy Manager: L Coote and J Golden Page 14 Review Date: December 2018